Long Term Care and COVID-19: a Survey of Policies in Ontario and British Columbia

A Light Shines in the Darkness by John Twohig Photography is licensed under CC BY-NC-ND 2.0.

In the past year, COVID-19 has caused a lot of pain and distress to people around the world, and it has also shed light on weaknesses in social and healthcare policies. In Canada, one weakness that has been highlighted by the pandemic lies in long-term care (LTC) homes. The following is a policy analysis of the difference in existing policies regarding LTC homes in Ontario and British Columbia (BC), the policies that provincial governments have implemented during the pandemic, and how these are influencing infection and mortality rates. This article focuses on Ontario and British Columbia as they have similar LTC care systems, but have had very different experiences throughout the pandemic. 

LTC homes provide a place where adults whose needs cannot be provided for by the community can live and receive help with most or all daily activities, together with access to 24-hour nursing or personal care. They involve more nursing and personal care than retirement homes or supportive housing. The organizations responsible for LTC homes and their funding vary from province to province. As of September 2020, Ontario has 626 LTC homes, of which 16% are publicly owned, 57% are owned by for-profit organizations, and 30% are owned by private not-for-profit organizations. In comparison, BC has a total of 293 LTC homes, of which 38% are publicly owned, 34% are owned by private for-profit organizations, and 28% are owned by private non-profit organizations. During the COVID-19 pandemic, LTC homes were disproportionately affected by the virus. According to a study published by the Canadian Institute for Health Information in June 2020, approximately 80% of COVID-19 deaths in Canada occurred in LTC facilities. This rate was worse in Ontario, while BC performed better. The rate of COVID-19 infections in LTC homes was 7.6% in Ontario as opposed to 1.7% in BC, and the mortality rate due to COVID-19 was 2.3% in Ontario compared to 0.6% in BC. 

The management of LTC homes before the pandemic is critical to understanding how COVID-19 impacted the two provinces. Despite similar management of long-term care homes and general similarities in public health infrastructure, BC saw better coordination between long-term care, public health, and hospitals during the pandemic. In BC, five regional health authorities oversee health services including hospitals and LTC homes, while in Ontario health services are overseen by 34 different units. As a result, it was much more straightforward for BC to channel its resources where they were most needed than for Ontario, where coordination was an existing weakness of the healthcare system due to its decentralized structure. In fact, this is precisely why healthcare services in Ontario were in the process of being integrated into coordinated “Ontario Health Teams” before the outbreak of the pandemic. “Ontario Health Teams” refer to teams of health professionals spanning diverse services including hospitals, doctors, and community care providers. This transition means that while healthcare in BC had been relatively stable pre-pandemic, it was not the case in Ontario; many leadership positions had not yet been filled when the pandemic began in March of 2020. Likewise, funding in BC was stable before the pandemic, as opposed to the reduced funding resulting from government directives in Ontario. Since these directives were implemented in 2019, access to funding has affected many aspects of provincial healthcare, such as the frequency of LTC home inspections While in BC all LTC homes are required to be comprehensively inspected every year, only 1.4% of homes in Ontario were comprehensively inspected in 2019. Since 2018, inspections in Ontario are conducted in response to complaints, rather than as a standard process as in BC. This has proven to be dangerous, as crucial hygiene practices, for example, hand hygiene, proper use of personal protective equipment, and proper cleaning practices were all assessed during these proactive inspections. Since moving to a reactive or incident-based system, there was a 30% decrease in violations reported in Ontario. However,  this decrease is not the result of better practices, but of fewer inspections. LTC homes that had not been assessed in a long time were left vulnerable to mistakes in a way that was not the case in BC. These safety issues could have made a significant difference in the outcomes of infection spread in the LTC homes. Furthermore, 63% of residents in Ontario shared rooms as opposed to only 24% in BC as of June 2020. This contributed to lower transmission rates of the virus in BC.

However, while pre-pandemic conditions in LTC homes were critical in influencing performance during the pandemic, provincial governments’ responses at the start of the pandemic must also be considered. BC announced a single site work policy about 2 weeks earlier than Ontario. This refers to a policy whereby staff were not allowed to work in more than one LTC home simultaneously. This was an important policy as up until it was passed, many workers in both provinces took up part-time jobs in multiple LTC homes due to low availability of full-time jobs and low wages. Staff working in more than one LTC home at a time could easily transmit the virus if they encountered an outbreak, especially at the beginning of the pandemic when PPE was hard to find. Moreover, existing full-time job opportunities and wages in BC were already better than Ontario pre-pandemic. This pattern remained true during the pandemic, where BC introduced measures to promote full-time work and standardized wages at the end of March. Ontario took a different approach, introducing a $4-per-hour pandemic pay bump for front-line workers in Ontario in April, which would be distributed either as a lump sum or a top-up on hourly wages depending on the number of hours worked. However, by June 2020 many front-line workers had not yet received this pandemic pay due to administrative delays. BC was also quicker to assemble supplies and support from specialized health teams for LTC homes. Part of this could have been due to the fact that the existing organization within BC’s healthcare system was more stable than the system being re-engineered in Ontario.  When the pandemic hit, BC was faster than Ontario in taking and enacting critical policy decisions to protect its LTC home residents and workers. It is possible that disorganization and underfunding in Ontario restricted their scope of action in the critical moment. However, the delay in the eventual implementation of key policies outlined important weaknesses in the very structure of  Ontario’s long-term care system. 

The existing infrastructure, working conditions of staff, and living conditions of residents were already more conducive to ensuring the well-being of LTC home residents and staff in BC before the pandemic. It is important for Ontario to use what happened during the pandemic to re-think its funding priorities, follow through with the implementation of Ontario Health Teams in a way that is not detrimental to the quality of care, and improve their response time in the face of health crises. The coordination of different branches of healthcare is crucial not only during a pandemic but also to ensure that people are supported in every aspect of their health by a team able to provide them with a holistic healthcare plan. BC’s centralized management of public health units has proved efficient during the pandemic, and a similar formula must be found and implemented in Ontario,  through policies like the formation of Ontario Health Teams. Moreover, LTC homes need to be inspected routinely and proactively, while LTC staff need to be given the necessary support to ensure residents are comfortable and given the best care available. It is critical to place vulnerable demographics including people living in LTC homes at the heart of policy decisions, rather than focusing on minimizing spending. Their safety and well-being need to be approached with a preventive lens as opposed to a curative one.