As Toronto’s Seniors Advocate, to better support the health and safety of our seniors and to ensure that large scale and deadly outbreaks in Ontario’s long-term care homes never happens again, I’m requesting that you consider and adopt the following recommendations: stabilize the long-term care workforce, accelerate vaccine distribution and increase efforts to promote vaccine confidence, strengthen partnerships between local hospitals, long-term care homes and congregate care settings, collect data on non-COVID deaths and the impact COVID-19 has had on the functional and psychosocial status and care needs of all residents, adopt emotion-centered approaches to care into Ontario’s Long-Term Care Homes Act (LTCHA) 2007 and Ontario Regulation 79/10, promote and invest in ageing in place, upgrade design standards to reduce crowding, reform the governance and accountability models of for-profit homes, and reform the reporting tools in suspected or known cases of elder abuse in homes.
The novel coronavirus (COVID-19) has been particularly devastating to our older adult population, especially in long-term care homes where, in too many cases, it has been running rampant. As the months pass, it has become clear that this public health emergency has quickly turned into a humanitarian crisis with seniors in long-term care accounting for nearly 70% of Ontario’s COVID-19 deaths.
As Toronto’s Seniors Advocate, to better support the health and safety of our seniors and to ensure that the tragedies that we’ve experienced throughout the pandemic never happens again in our province, I’m requesting that you review the accompanying recommendations for consideration and adoption.
1) Stabilize the Long-Term Care Workforce
Far too many of Ontario’s long-term care homes continue to face dangerous staffing shortages. This is a serious and significant contributing factor to the increase in recorded COVID-19 outbreaks and deaths that are ravaging the very places that should be safe, healthy and caring environments.
The majority of staff in both long-term care homes and other congregate care settings such as retirement homes and group homes are offered part-time, rather full-time work. The key difference between the two includes the number of paid sick days. A full-time unionized worker will receive 10-14 days of paid sick leave every year, while a part-time worker will only receive 1-3 days. This is why many workers have had to make the difficult choice of reporting to work with potential COVID-19 symptoms or staying home and missing a day without pay.
Our province needs to invest in our workforce through offering more full-time employment opportunities, greater pay, heightened benefits and increased sick days. This would ultimately resolve the recruitment and
retention issues that were previously present in the sector, prior to the pandemic. The pay-out of this investment in our workforce will show through the enhanced quality of care that would be delivered daily to our most vulnerable.
2) Accelerate Vaccine Distribution & Promote Vaccine Confidence
To stop and slow the spread of infection, Ontario needed to accelerate the distribution of the vaccine around the clock, as opposed to operating on “banker’s hours”, to complete the vaccination of all residents, caregivers and workers in long-term care homes and congregate care settings. Clear, transparent and multilingual education and communication campaigns should’ve been distributed, as part of the vaccination roll-out plans.
Many racialized and Indigenous populations have historic mistrusts of vaccines and health programs. That is why Ontario should’ve made every effort to work collaboratively with key partners that have built strong relationships with such communities to address vaccine hesitancy in workers in long-term care homes and congregate care settings. This would’ve ensured that they received clear information about the vaccine from a trusted source and were able to access it conveniently. For those workers that needed to visit vaccination clinics to receive the vaccine, paid time off and/or reimbursement of travel expenses should’ve been offered.
3) Strengthen Partnerships between Local Hospitals, Long-Term Care Homes & Congregate Care Settings
During the pandemic, it became abundantly clear through the staffing and supply shortages long-term care homes faced, many homes and their residents wouldn’t have survived without the interventions of local hospitals. The recent partnerships that were formed between local hospitals and long-term care allowed for these homes to be temporarily brought into the healthcare system. Upon working with homes, local hospitals ensured that they weren’t taking over the home in a punitive way, but many saw it as an opportunity to educate and train management and staff on current gaps in their infection, prevention and control measures, communication techniques, and delivery of care. Some of the benefits of these partnerships were seen through the management of outbreaks by Sunnybrook Health Sciences Centre at two homes located in my ward, Isabel and Arthur Meighen Manor and The Briton House, and additionally through Michael Garron Hospital’s timely vaccine roll-out plan. This spirit of collaboration and coordination between the health and long-term care systems needs to be retained, but more importantly, strengthened post-pandemic.
4) Collect Data on Non-COVID-19 Deaths & Impact COVID-19 has had on the Functional and Psychosocial Status and Care Needs of All Residents
As reported by experts, residents in long-term care and congregate care settings have experienced severe and potentially irreversible physical, cognitive, psychological, and functional declines as a result of actions taken by homes during the pandemic, including blanket no-visitor policies. Observed harms includes an increase in the prescription of antipsychotic drugs to residents and antidepressants to residents.
In order to better understand and assess the needs and challenges of residents, the Ministries of Health and Long-Term Care must provide additional resources to long-term care homes to collect data on non-COVID-19 deaths, and the impact COVID-19 has had on the functional and psychosocial status of all residents.
This public data will not only inform the current and future standards of care, but may also validate the need for emotion-centered approaches to care.
5) Adopt Emotion-Centered Approaches to Care into Ontario’s Long-Term Care Homes Act, 2007 (LTCHA) and Ontario Regulation 79/10
In the midst of this pandemic, we cannot lose sight of the importance of planning for our future. In Toronto, I led an initiative to adopt emotion-centered approaches to care in our City’s 10 long-term care homes. I recommend that this approach be considered for homes across our Province with an update to the care standards as outlined in Ontario’s Long-Term Care Homes Act, 2007 (LTCHA) and Ontario Regulation 79/10. This approach to care has proven to benefit residents through reductions in unintended weight loss, falls, negative responsive behaviors, the use of antipsychotics and cost-savings to our healthcare system. In order to successfully incorporate these guiding principles within our homes, staffing ratios must be increased.
This request, which was listed as a recommendation in the 2019 public Inquiry, is crucial, as staff shift the focus of their care from a task-based, to an emotion-centred approach. With the increases made to staffing ratios, consideration should also be made to ensure their jobs become less precarious and transient through the forms of better compensation, benefits and the ability to work in one home.
6) Promote & Invest in Ageing in Place
While the systemic challenges present in Ontario’s long-term care system have been entrenched for decades, this pandemic has further discouraged many older adults from wanting to enter the system in the first place. According to a recent poll, over 90% of older adults plan to age in place.
With seniors being the fastest growing age group in Ontario, our province needs to begin exploring new, and expanding current, at-home supports and care to allow for more older adults to age in place. Unfortunately, in comparison to other OECD countries, Canada is ranked as having one of the lowest levels of spending on home care, as reported by Queen’s University.
As co-chair of the Toronto Seniors Strategy Accountability Table with Dr. Samir Sinha from Sinai Health and University Health Network, we had the pleasure of initiating a City of Toronto HomeShare program, which matches older adults aged 55+ with a spare room in their home with a post-secondary student seeking affordable housing. In exchange for reduced rent, the student provides up to seven hours per week of companionship and light assistance with household tasks. This program empowers older adults wishing to remain in their homes with a means of obtaining additional income, and help around the home. In addition to addressing the lack of affordable housing in the City, particularly among students, this initiative also combats social isolation and loneliness.
Moreover, at 400 Walmer, which is a naturally-occurring retirement community in my ward, I was pleased to work with the University Health Network, the Landlord, Property Manager and founder of OASIS, Christine McMillian, to initiate an OASIS program within the building. This program is designed to strengthen and sustain healthy communities of older adults by addressing important determinants of healthy aging such as isolation, nutrition, physical fitness, and sense of purpose. OASIS, which is a preventative alternative to long-term care, supports ageing well, and promotes living independently. The purpose of this program is to provide a supportive living program for older adults that builds community among members in the setting of an existing private sector apartment building through collaboration with public sector, not-for-profit, and private sector organizations.
7) Upgrade Design Standards to Combat Crowding
It’s clear that COVID-19 thrives in congregate settings and leads to widespread transmission. As reported by experts, more cases in deaths occurred in homes with high levels of crowding (2 or more occupants per room and bathroom), compared to homes with low levels of crowding (less than 2 occupants per room and bathroom). In an effort to address this, the Commission suggested decanting crowded homes in their first interim recommendations, which I applauded. However, I’d take this a step further and suggest that all long-term care homes with design standards that meet or fall below those set in from 1972, which allows for more than 2 occupants per a room (bed classes B, C, and D), be mandatorily advised to upgrade to design standards from 1998-1999, which sets a maximum of 2 occupants per a room (A or new bed classes). The Ministry should be able to support these retrofits through capital funds.
8) Reform the Governance and Accountability Models of For-Profit Long-Term Care
As noted by experts tracking Ontario’s cases and death rates in long-term care, for-profit homes have significantly worse COVID-19 outcomes compared to municipal and non-profit facilities. The contributing factors that have resulted in for-profit homes performing worse include, but not limited to, older design standards, chain ownership, lack of investment in the workforce, and prioritization of shareholders over delivery of care. That is why, Ontario must reform the governance and accountability models of for-profit long-term care homes so that profits never come before safety and care.
Upon completing inspections, one mechanism that could be useful is to develop a colour-coded rating system, based on the City of Toronto’s DineSafe program. Depending on the outcomes of the Long-Term Care Home Quality Inspection Program (LQIP) and Resident Quality Inspections (RQI), identifiers for each category, which would be posted on the main doors of the home, could be as follows: red- “unsatisfactory”, orange- “needs improvement”, yellow- “needs some improvement” and green- “pass”. This would publicly put pressure and hold homes accountable to act immediately on the findings listed in the reports and be used as a transparency tool for residents, caregivers, visitors, family members, loved ones and more importantly, potential incoming residents. To ensure that this rating system works efficiently and effectively, timely follow-up inspections would be required.
While our destination maybe to have a fully public system, it is evident that in the interim, improved transparency and accountability is needed in the for-profit sector.
9) Reform the Reporting Tools in Suspected or Known Cases of Elder Abuse in Homes
Four out of five of Ontario’s long-term care homes that were taken over by the Canadian Armed Forces during the first wave reported disturbing and inhumane conditions in homes including cockroach infestations, aggressive feeding practices, and infected pressure ulcers. Under the Canadian Criminal Code, elder abuse can be categorized as financial, physical, sexual, and psychological abuse and active neglect. While in Ontario it is mandatory to report suspected or known cases of elder abuse when an older adult resides in a long-term care or retirement homes, reports must solely be made to the Ministry of Long-Term Care to initiate an inspection and not to the local police station. That is why, during such inspections, the Ministry of Long-Term Care should immediately partner with the Ministry of the Attorney General, Ontario Provincial Police and other municipal law enforcement services to complete investigations.
Thank you to the Commissioners for taking the time to review my submission and for their continued work to support our seniors.
We owe it to our long-term care homes staff and residents, along with their caregivers, families and friends, to take the necessary steps to ensure that they’re provided the highest standards of safety and care. Those who we’ve lost to COVID-19 deserve nothing less than transformational change.
Let this be their legacy.
Councillor Josh Matlow, Toronto’s Seniors Advocate, City Councillor, Toronto – St. Paul’s