Long-term Care System
Inquiry--Debate Adjourned
October 27, 2020
Rose pursuant to notice of September 30, 2020:
That she will call the attention of the Senate to weaknesses within Canada’s long-term care system, which have been exposed by the COVID-19 pandemic.
She said: Honourable senators, in the early stages of the COVID-19 pandemic, Canadians were staggered to learn that the vast majority of COVID-related deaths occurred in long-term care homes. As of June, according to the International Long-term Care Policy Network, 85% of all COVID-related deaths in Canada — 6,236 out of a total of 7,326 deaths — were residents in long-term care settings. These figures spurred a serious policy discussion begging the question: How did this happen?
Canada is not an anomaly. Many countries experienced high long-term care mortality rates. In June, the Canadian Institute for Health Information released a report titled Pandemic Experience in the Long-term Care Sector: How Does Canada Compare With Other Countries? They examined the similarities and differences between Canada’s pandemic experience in long-term care and that of 16 other OECD countries, including Australia, Spain, Germany and the United Kingdom. The proportion of deaths that occurred in long-term care homes varied substantially across countries, ranging from 28% in Australia to 66% in Spain, with an overall OECD average of 38%.
The Canadian Armed Forces report released on May 14, 2020, unveiled disturbing and unacceptable conditions found in five Ontario long-term care homes, which were overwhelmed by COVID-19 cases and in desperate need of humanitarian relief. Their observations included rampant cockroach infestations, rotten food and unchanged soiled beds. Canadian Armed Forces personnel witnessed employees reuse unsterilized medical supplies and detailed the ways in which residents were neglected by ill-trained staff.
While these findings paint a grim picture of the state of our long-term care system, it should come as no surprise. Canada’s long-term care system was wholly unprepared and under-equipped for the COVID-19 pandemic. Very few homes had strategies in place to protect their residents in case of a public health emergency.
For decades, health experts have warned us about the dire state of Canada’s long-term care system. One only needs to look back at the last 20 years to find countless inquiries, expert-led panels and task forces mandated to study the shortcomings of the long-term care system at great length. There is no shortage of expert recommendations to create higher standards of care.
I am especially reminded of the Special Senate Committee on Aging that was created in November of 2006 to “examine and report upon the implications of an ageing society in Canada. . . .” Over the course of two and a half years, the committee studied the issue of aging in our society in relation to housing and transportation needs, abuse and neglect, and health promotion and prevention. The three-phase study aimed to identify key public policy issues and present a set of potential solutions to address these issues. In their final report, Canada’s Aging Population: Seizing the Opportunity, the committee published 32 recommendations shaped by the wisdom of expert witnesses on how to better embrace the challenges of an aging population.
Honourable senators, it is evident that Canada is not short of sound evidence on how to achieve lasting change within the long-term care sector. Many, like the Special Senate Committee on Aging, have paved the way for constructive policy, discussion and information-sharing. Yet, despite this, tragic events continue to happen, deep-rooted issues remain unchanged and concern for the well-being and safety of our frail elderly deepens, even now, with each passing week. The purpose of this inquiry is not to shout into the void, but to highlight with great urgency the need to implement real solutions to the issues that have plagued our most vulnerable population. Long-term care is a fractured sector. There is no question that these issues exacerbated by the COVID-19 pandemic call for extraordinary and immediate measures.
At the very least, we must begin by examining clear, simple fixes that are easy to implement. In June 2020, the Royal Society of Canada’s task force on COVID-19 released a report titledRestoring Trust: COVID-19 and The Future of Long-Term Care, which outlines the need for national standards for staff working in long-term care homes. They write:
Workforce reform and redesign will result in immediate benefit to older Canadians living in nursing homes and is necessary for sustained change. It will also improve, at a minimum, quality of care so that nursing homes are able to reduce unnecessary transfers to hospitals, reduce workforce injury claims, and interface more effectively with home and community care.
They advise provincial and territorial governments, supported by funding from the federal government, to implement appropriate pay and benefits, including sick leave, for the large and critical unregulated workforce of direct care aids and personal support workers. The report also recommends minimum education standards for the unregulated workforce in long-term care homes with an emphasis on continuing training and orientation.
Several other health experts in long-term care have advocated for similar recommendations. At the beginning of April, the Standing Senate Committee on Social Affairs, Science and Technology was mandated to study the federal government’s response to the COVID-19 pandemic. Expert witnesses emphasized that the pandemic has highlighted issues that have long existed within the long-term care sector, such as understaffing, inadequate training, low wages, unregulated support workers and the lack of a mandatory national accreditation process. Witnesses suggested that federal legislation could require mandatory accreditation of long-term care, as well as national standards for equal access and consistent quality in long-term care across Canada.
One witness, Miranda Ferrier, the president of the Canadian Support Workers Association and it’s Ontario chapter, the Ontario Personal Support Workers Association, noted that the organization has been:
. . . actively advocating for self-regulation of the personal support worker here in Ontario for the past five years.
In fact, Quebec and Ontario responded to the LTC crisis of the first wave over the summer. The Premier of Quebec launched a project to hire and train 10,000 new long-term care staff, and the Ontario government pledged to increase funding, implement better working conditions and modernize the regulatory framework. But already, now in October, we see more COVID outbreaks in long-term care homes just on the verge of being out of control once again.
In addition to the long-term care workforce crisis, there are other areas that demand our attention. For example, it is widely known that much of the long-term care infrastructure is outdated. In some long-term care homes, as many as four residents are housed together in a single room, with a thin curtain as the only option for privacy.
A report published in the Canadian Medical Association Journal on August 17 found that:
. . . the risk of an outbreak of COVID-19 at an LTC home was related to the COVID-19 incidence rate in the public health unit region surrounding the home, —
— that is, in the community —
— its total number of beds and older design standards . . .
The report analyzed 623 long-term care homes in Ontario, some of which still adhere to design standards from 1972.
Another report titled Re-imagining Long-term Residential Care in the COVID-19 Crisis, published in April of 2020 by the Canadian Centre for Policy Alternatives, highlights the need to redesign long-term care homes. They write:
It is important though that these new designs not only allow for private rooms and outdoor spaces, non-slip floors and smaller units, good sight lines and communication systems as many do, but also that they have appropriate space for in‑house food, laundry and cleaning services that ensure the safety of staff.
Long-term care homes should not be warehouses or storage units for our elderly, but warm living spaces that provide them a sense of community.
While we examine these clear and attainable short-term solutions, we should take the opportunity to think about creating long-term, deep-rooted change within the sector. The COVID-19 pandemic has rejuvenated and inspired policy discussions by health experts across the nation. Many will look to us, parliamentarians, for guidance and the initiation of the important conversation about ways in which we can reimagine and reshape the long-term care sector.
Some may question why this inquiry was launched in the Senate, at this specific moment in time. We will remind them that while there was temptation to launch an inquiry at the onset of the pandemic, we realized that we needed distance and perspective to properly evaluate the situation. That sense of perspective is the epitome of independent sober second thought, the guiding principle of our institution. We have a duty to review legislation and policy decisions in ways that are free from electoral pressures. We are able to embody futuristic thinking, influenced by well-rounded and distinct perspectives. The Senate is the ideal place to consider the ways in which we tend to the elderly in our society.
We must ask ourselves: How do we deliver health care services to our aging population? Why do we invest more in acute hospital care and less in community care? There must be a critical analysis of the status quo.
A report titled Seniors in Transition: Exploring Pathways Across the Care Continuum, released by the Canadian Institute for Health Information in 2017, posed a number of questions to help understand the care paths of seniors, over time, through the continuing care system. They found in their study that one in five seniors who entered residential care might have been able to be supported in home care. They also found that seniors disproportionately rely on hospital services. Based on their analysis, seniors represent 34% of hospital cases and 58% of hospital days. They write:
If we assume that health services will be provided in the future as they have been in the past, health systems would need to double existing residential care capacity over the next 20 years to keep up with population growth. Clearly, this is not a feasible or appropriate option. Ensuring there is capacity to meet the pending demand of a growing population of seniors requires more than just building new beds; it means transforming the way care is provided across the continuum.
Canada has a growing aging population with a spectrum of needs. Long-term care is part of a larger framework which also includes aging in place, wellness, health and social services. While it is important to invest in the sustainability of the long-term care sector, we should also think about supporting community-based care options that will allow seniors to remain at home or in their communities as long as possible. If given the choice, over 85% of older adults would prefer to age in place within their own homes and communities according to the National Institute on Ageing’s 2019 white paper.
As my colleagues will note, aging in place is a subject close to my heart. My vision for the future includes the creation of a “healthmobile” — a mobile team of multidisciplinary health care professionals who would circulate in the community and provide health and social services to seniors on a regular basis. They would be able to get prescriptions renewed, have access to a multitude of easily administered tests with mobile equipment, and consult with a number of allied health professionals. A service like a healthmobile would enable seniors to receive immediate medical attention within the comfort of their home or community, and keep them away from emergency rooms. Community-based care would also help them better manage activities of daily living.
Honourable colleagues, I recognize that the federal government cannot dictate the ways in which health care services are delivered. This is not within our jurisdiction. However, the high mortality rates being recorded in our long-term care homes is the price we pay as a society for our refusal to act on all those studies that have come before. This is a collective national failure.
The Special Senate Committee on Aging dedicated their final report to:
. . . the seniors who have not had the support they need as our society has tried to come to terms with monumental societal shifts which have inadvertently shunted them to the sidelines.
And the ones “. . . who have held on to the hope of a better world in which to age.”
I, too, dedicate this inquiry —
Your time has expired. Would you like to ask for five more minutes?
Two minutes.
I, too, dedicate this inquiry to the very same seniors who have served as our caregivers, veterans and nation builders, and who deserve a better and more dignified aging experience, not tomorrow or within a decade, but now. Honourable senators, the urgency is now. Thank you.
Senator Seidman, thank you for your inquiry and for starting off this very important debate with such eloquent words, and words of hope, and a call to action to all of us in this chamber.
I rise today to add my voice to Senator Judith Seidman’s important inquiry into Canada’s long-term care system and prevalent weaknesses that have been exposed by the COVID-19 pandemic. This subject is very close to my heart as well, and I hope I’m able to get through this without my emotions getting the better of me, because my own mother is a resident in a long-term care home in Vancouver, B.C.
I would like to acknowledge the caregivers at her residence, some who have become extensions of our family, more so during the past number of months while the home has been under lockdown. Without the trust that has been established over a seven-year period, I would be sick with worry beyond measure.
This year has been a very challenging time for our nation and around the world that has brought grief and financial difficulties to so many, a complete disruption to daily life, unprecedented mental health challenges, coupled with economic hardships that have pushed individuals, families, businesses and organizations to their limits. One of the hardest and harshest of realities has been the lockdown of the long-term care homes and the forced separation of those in care from their families.
From the onset of this pandemic, Canadians were asked to help protect those at the highest risk of being infected, namely the elderly. While a majority of seniors over 65 years of age in Canada live at home, with family or are living independently, 4% of seniors live in long-term care facilities, which provide them full service throughout the day, and 3% live in assisted-living facilities.
By June of this year, just three months after the World Health Organization declared the pandemic, it was reported by the Canadian Institute for Health Information that 81% of COVID-19-related deaths in Canada were residents of nursing or retirement homes. By August, the National Institute on Aging reported that long-term care residents and staff comprised 23% of COVID-19 cases and 77% of COVID-19 deaths in Canada.
Senator Seidman already spoke about the Canadian Armed Forces issuing their heartbreaking interim report. I, too, thought about some of the tragic cases and the urgent need to do things better.
Compared to other OECD countries, Canada averages 2.3 nurse aides/personal support workers per 100 long-term care residents aged 65 and over. This figure is comparable to 2.4 in Germany and 2.9 in Ireland. The United Kingdom is significantly behind at 1.2, while the United States is ahead with 4 per 100 long-term care residents.
In contrast, some long-term care centres were able to minimize exposure to COVID-19 and hired additional staff at the onset of the pandemic to better support the residents, while family members were asked to stay home. I can speak from personal experience that our family care team has worked very closely with the care staff at my mother’s residence to add support when and where it was needed most, often during meal times when extra hands were always welcomed.
However, when family members were prohibited from visiting during the pandemic, this added support that is often not documented or accounted for revealed the gap in quality care as personal support workers were stretched thin and unable to give the kind of service they normally could, because there is only so much one person can humanly do.
To make up for the support that visiting families naturally add to the overall care of the residents, this is where government should and must fill the gap through additional funding to hire and train more personal support workers where needed.
Some specific gaps that I experienced and observed during this period came to light when my mother had a fall a few months ago. It was one of the most difficult phone calls I took, because my mother, who has advanced dementia, would have to be sent to emergency at a nearby hospital. I could follow the ambulance but I wouldn’t be guaranteed access to my mother in emergency. We knew there were delays and she could be there for hours.
To send a person with advanced dementia into the unknown seemed like a worse option than keeping her at the residence with her injury. Because of her dementia, she has no short-term memory and she experiences pain differently, it seemed as though she was not as injured as we originally thought, but she was clearly in pain, and they did their best to manage that pain. She was given some therapy, but at this time I can tell you that, since her fall, she has never recovered. She is in a wheelchair, and — I guess thankfully — with her advanced dementia, she has forgotten that she used to walk and sometimes run and sometimes dance.
I don’t want to generalize and say that the health care system is broken, but it is accurate to say that there are gaps between the parts that make up our system, even in the same city, and most likely in the province and across our country, with interprovincial challenges.
Related to this gap, between one institution and another, as we experienced as a family, is the one caused by a language barrier. I’m concerned about the access to medical support due to language barriers for seniors whose first language is not English or French in some parts of our country. While there is limited conclusive data at this time regarding language barriers affecting seniors’ access to health care during the pandemic, language barriers were known to complicate general care, even before COVID-19.
In 2015, the Essex County Chinese Canadian Association concluded a two-year study revealing that language was the main barrier for Chinese seniors accessing health care. For residents who do not speak English or French fluently or who do not have a family advocate who speaks English or French fluently, it would be more difficult to seek the appropriate medical attention, especially during this period.
I have regular and clear lines of communication with both management and care staff at my mother’s care home, but it is a very complex system at the best of times, and I have encountered major communication challenges speaking the same language, let alone if I had to try to speak a second language. I often wonder how other families are able to navigate the complex labyrinth of our health care system if there are language barriers. Would their loved ones have gotten the same kind of care my mother was able to receive?
Constituents have contacted me on several occasions because they could not properly communicate with staff at long-term facilities and hospitals. They were stuck when their queries went unanswered, and they were unable to ask for medical assistance. Imagine the heightened pain and fear caused by a language barrier, especially during these unprecedented times.
Last, I wish to highlight the mental and emotional strain that has one of the most difficult challenges families and long-term care residents have had to face during these times. In my mother’s care home, there is a limit of only one designated visitor per resident. Senator Plett mentioned he has two designated family members who can go. As the eldest daughter, I’m the designated visitor. No one else in my family has seen my mother, face to face, since the lockdown began months ago.
Like my mother, long-term care residents have spent far less time in the company of loved ones living outside the facility. A combination of the lack of social interaction and visits from loved ones, the fear of illness and death from COVID-19 and a reduction in physical activity have contributed to increased rates of isolation, loneliness and depression among long-term care residents. Video communication, standing in front of windows or speaking on the phone have become alternative means of communication between the residents and their loved ones. However, it is not a replacement for in-person visits — not even close.
As we can appreciate, seniors are less likely to be digitally literate. Some, like my mother, have failing eyesight and cannot see images clearly on a screen, and voices can sound muffled and less audible if there is background noise or a bad connection.
There are sad stories of seniors who have passed away during the pandemic, not because of COVID-19 but because of sheer loneliness and quality of life after being separated suddenly from their loved ones. Cognitive impairment in seniors in long-term care, such as dementia, poses an additional hardship. Long-term care residents with dementia have been less likely to see loved ones and fading familiar faces since the pandemic began. In addition to the loneliness caused, the isolation could also accelerate the deterioration of memories of their loved ones. The use of personal protective equipment has also been disorienting for some dementia patients, as they are less likely to recognize a person wearing a face mask, including personal support workers.
In truth, the remedy to lockdown and shutting out families to protect residents from the outside world is perhaps worse than the virus itself. Residents have suffered, and some are dying, lonely and afraid.
Honourable senators, I share with you these concerns that have been brought to light. For me personally, as well as for all of us as senators over the course of the COVID-19 pandemic crisis, I know this is a complex issue and one that needs to be addressed with care and urgency to ensure that, above all, we protect our veterans, our parents and grandparents and the most vulnerable seniors in care.
We must work to find solutions to fill the gaps in our systems with effective measures and adequate funding, some which have been outlined by Senator Seidman already. We must do better than the average of 2.3 personal support workers per 100 long-term care residents. Greater and better management of funds will ensure staffing needs are met and ultimately ensure better care for residents. The long-term care system can be improved and we must not ignore the issues that have been brought to light. The lives of our loved ones depend on what we do better together.
I would like to conclude by commending our health care workers who are on the front lines in our care homes and fighting every day to do their best with the given equipment and resources they have despite the many challenges of this current situation. They are doing so at the risk of their own health, for the well-being of others. In fact, I was talking to one of the nurses on duty who said she is not able to visit her mother in care because of the work she is doing on the front lines. They are making great sacrifices for our family members. For that we should all be grateful. As the daughter of one such resident in care, I am most grateful. Thank you.
