LONG-TERM CARE IN SASK.
Advocates say system must be fixed
Saskatchewan's seniors minister is hoping to learn from tragedy, as he faces calls to reform a longterm care system devastated by the COVID -19 pandemic.
He said changes are likely to come, though he can't yet say how.
“I'm not going to jump the gun and say what they might be, because I just don't know at this point,” said Everett Hindley. “We'll be taking a hard long look at this, and I expect there will be changes.”
Hindley is waiting for a report from Saskatchewan's ombudsman, who will examine what went wrong when a COVID -19 outbreak at Extendicare Parkside in Regina cost 41 lives. The report aims to look beyond one single home, and Hindley promised to take her recommendations seriously.
“If the ombudsman comes back to us … and recommends that there needs to be some changes or improvements, of course we would take a very, very close and hard look at that,” he said. “We just need to make sure that we're doing better.”
But families, advocates, unions, workers and experts wonder why the government needs to wait for another report when it already has piles of them. They say it's already clear what's wrong, and how to fix it.
“Let's not see more reports coming out with recommendations,” Thomas Hadjistavropoulos, director of the Centre on Aging and Health at the University of Regina. “I think there's plenty of those. Let us see some action. Let us see some standards and legislation, some budget changes. This is the time.”
He said the main challenge is resources. In his view, the pandemic only compounded the issue.
“COVID has not caused the problems that we're facing,” he said. “COVID has exposed the problems that have already been there. And we're now facing the consequences of these problems.”
Hadjistavropoulos thinks the public was unaware just how serious those problems were. COVID-19, with all the pain and loss it unleashed on the homes, may also be the wake-up call the public needed.
“If there is any silver lining to COVID, it is that it brings to the forefront the problems and leads to commitment that the problems will be ameliorated,” he said.
Brian Harris, vice-president of the seniors advocacy group Saskatchewan Seniors Mechanism (SSM), isn't optimistic change will come now any more than it came after past reports exposed pressures on long-term care. Still, now is the best time to push for it — since standards in long-term care are finally getting the attention they deserve.
“The system has sort of bumped along without much public scrutiny, out of sight out of mind,” he said. “Now that we have outbreaks in some of these facilities, and particularly serious outbreaks, it's a little more in the public eye.
“But after the pandemic finally goes away is everything going to just go back to the way it always was?”
Hindley pointed to action the Saskatchewan Health Authority (SHA) took during the pandemic, like conducting site visits of all long-term care homes in the province and sharing the results with their management. He also emphasized the accreditation process, quality of care co-ordinators and critical incident reporting that was already in place. But he accepts a need to do more to ensure accountability.
“You're right, we need to make sure that the guidelines are being followed, and that's how we ensure that the residents of these homes are receiving the best possible care,” he said.
Families and home operators have clear ideas about what needs to change. Leslie Bell, whose husband died after contracting COVID-19 at Saskatoon's Luther Special Care Home, wants better training and supervision of care staff who work with dementia patients. Though her husband wasn't in a ward-style room, she supports calls to put an end to four-bed accommodations in long-term care.
But she isn't holding her breath for action.
“They restudy and restudy it and then they shelve the recommendations,” she said. “I think it's been an ongoing pass the buck.”
Wayne Nogier, the CEO of Mont St. Joseph Home in Prince Albert, wants clearer guidelines. He wants higher standards. And he wants the money to hire the staff he needs to meet them.
“We need staffing so that every resident gets four hours of direct resident care per day,” he said.
Mont St. Joseph only gets enough money to support 2.8 hours of care daily for most residents, with a bit more in a unit for higher needs residents.
Nogier figures he needs to boost his staffing contingent by about 20 full-time equivalents.
“We need to see a significant improvement in that per-resident-day costing,” Nogier said.
Extendicare, which operates the only five for-profit homes in Saskatchewan, is on the same wavelength. In a statement, it said provincially funded staffing levels currently amount to about 2.8 to 2.9 hours of care per resident per day.
“Extendicare believes a move to four hours of care per resident per day is appropriate, in keeping with widely recognized, international standards of care,” said Extendicare spokesperson Laura Gallant.
Ontario committed to that standard in December. Gallant said Extendicare is advocating for all provinces to follow suit, and is in talks with the SHA.
The SHA was unable to provide data on the average number of care workers per resident or care hours per day in the long-term system as a whole, saying it does not track that information. As of press time, it was not able to specify the amount of money it spends per resident per day to fund care homes.
Mont St. Joseph faced an outbreak that began in December and eventually infected 27 residents, as of the date of an interview last month. Seven of them died. Throughout it all, Nogier felt like he was fighting the outbreak short-handed.
“A change in the standards to reflect an adequate level of hours of care would have increased my full-time equivalents in the building, which would have put me in a better situation,” he said.
Hindley responded that the Saskatchewan Party government has increased staffing levels in longterm care by 700 positions over its tenure — and now plans to add 300 more. But he's not yet sold on the idea of minimum staffing ratios or hours of care. He said the current policy, which allows homes to set their own staffing mix, allows for flexibility.
Harris doesn't buy that argument.
“It is simply avoiding the issue,” said the SSM vice-president. “If there is no standard whatsoever, how can you judge whether people are being given the appropriate amount of care?”
But Harris doesn't want the soul-searching in seniors care to stop at the homes themselves. He thinks the pandemic offers a chance for a deeper examination of how Saskatchewan supports older adults. “We need to rethink the notion of care,” he said.
He faulted the existing homecare system for limiting itself to medical needs, like nurse visits or medication management. Harris thinks more support for daily tasks could help people stay in their homes — and out of institutions that leave them vulnerable.
Paula Sostorics, whose mother, Arlene, died during an outbreak at Santa Maria, thinks her mom would have been able to stay at home with that kind of publicly funded support — especially on medication management and baths.
“That's really what could have changed it for her,” said Sostorics.
According to Hindley, Saskatchewan spends $195 million annually on home care, a 50 per cent increase since the government took office. But that's during a period when health expenditures overall almost doubled.
The Saskatchewan NDP made home care a major part of its platform in the 2020 provincial election, committing to build “the best home care in Canada” if it formed government. It also promised to legislate minimum standards for long-term care and end understaffing by hiring 450 nurses and 500 continuing care aides.
The party didn't rack up electoral gains with its commitments. The election preceded the terrible outbreaks of November, December and January. But NDP Leader Ryan Meili feels that the tragedies that followed should not have been a surprise.
“That was predictable,” he said. “We saw what happened in Ontario and Quebec and around the world, and it was preventable. They could have brought on more staff, they could have increased their capacity to protect those seniors.”
Meili argued that the for-profit care model simply isn't working. He sees no coincidence that homes with the worst ventilation, the worst crowding and the worst staffing levels are also those with the worst outbreaks. He doesn't think there's anything to prevent another crisis from coming down the road.
“There's no rules in place. They've done nothing to change the requirements, and that's what we need,” Meili said. “We need minimum standards of care, we need to eliminate any more than two to a room and eliminate it permanently. We need to step up to appropriate levels, and we need to remove the worst actors.”
Extendicare resisted reports that ventilation at Parkside was a significant problem, with Gallant saying that the company engaged independent contractors to examine air quality and air flow. “To date, they have not provided any conclusions indicating any issues with air quality,” she said. But she said further analysis is ahead.
The long-term care system is expected to face mounting pressures over the decades to come, as a surge of baby boomers reach the age categories where home care and long-term care use is highest. The number of Saskatchewan people aged 75 and over is projected to grow 68.5 per cent between now and 2035, according to Statistics Canada, reaching 140,000 that year.
There are approximately 8,700 long-term care beds in Saskatchewan. About 370 of those spaces are located in four-bed rooms, a factor the SHA'S CEO said may have facilitated the spread of the coronavirus at Extendicare Parkside.
Hindley noted those rooms are “extremely uncommon.” Only seven of 151 homes still have them. But despite the risks, it's unclear how long they'll remain in place. Hindley said the province is working to find the best way to move away from four-bed rooms.
“We need to make sure that there's a place for those people to go too,” Hindley responded. “We're working through the SHA to try to determine how we can do that, I would say, as quickly as possible.”
Extendicare has design plans for new homes with single-bed rooms, according to Gallant. All five of its homes were constructed between
1963 and 1971. Gallant acknowledged that aging infrastructure is a significant challenge, as the pandemic “has made abundantly clear in the outbreak outcomes of these homes compared to newer buildings.”
Gallant called for provincial support to build more modern infrastructure. She said Ontario shows the way, where Extendicare expects to have six redevelopment projects underway by the end of 2022 worth $400 million.
“In Saskatchewan, we require provincial approval before we can proceed with replacing our older homes,” she said. “We have renewed hope that Saskatchewan and other provinces will act quickly on this front with the heightened knowledge of the risk older homes present to the health and safety of residents.”
There's no timeline on when that will happen. Pam Moore, whose mother survived COVID -19 while living in Parkside, said the province shouldn't be comfortable with four-bed rooms, even for the shortterm. There's just too much risk.
Since the pandemic, Parkside has limited capacity to two residents per room. Moore worries about how long it will stay that way.
“If we went back to the four beds, I think that would be terrible.”
Moore has noticed a stark difference in her mother's care since the SHA took over operation of the Regina care home as part of a co-management agreement with Extendicare — a response to the worst care home outbreak in Saskatchewan.
The arrangement recently came to an end.
In her mind, it's been an experiment in what happens when a care home runs like it should. She noticed staffing levels went up in relation to the number of patients. She said the difference is “tremendous.”
“The residents are thriving,” Moore said. “It's astounding... I can't help but feel that it's due to the care that she's getting, and the attention.”
Her mother, who had lost considerable weight during her stay, has recently put on 20 pounds. She seems healthier and happier.
“I hope this lasts,” she said. “We're very cautiously hopeful that they will be kept accountable, that they will keep the staff the same as it is now, not cut back because the numbers are down.”
The deaths in long-term care have been a national tragedy, not just a Saskatchewan one. Canada has among the highest percentage of COVID-19 related deaths in long-term care out of any developed country in the world. And Canada lags behind the developed country average on health workers in long-term care per 100 residents, according to the Canadian Institute for Health Information, with a rate roughly half that of leaders like the Netherlands and Norway.
There are increasing calls for a national long-term care strategy, and Prime Minister Justin Trudeau has signalled that provinces that don't want to improve standards might not get funding.
Hindley said Saskatchewan requires federal support. “This affects the entire country,” he said. But Premier Scott Moe has appeared skeptical about the prospect of conditions on federal health funding to ensure it's directed at long-term care. He said dedicated funding should come over and above the money Saskatchewan needs for core health services.
Meili suggested the province should be more open to a federal plan, so long as it comes with ample support.
“If the federal government wants us to have standards and meet them, I applaud that. But it better come with the dollars — the transfer funds — to be able to meet that.”
If the pandemic doesn't lead to lasting change, Hadjistavropoulos doesn't know what will.
“I can't imagine anything else happening that would be so revealing of the reality of long-term care,” he said. “I don't know what else it would take. I think it's a great time to do it, because it's at the forefront.”
We need to make sure that the guidelines are being followed, and that's how we ensure that the residents of these homes are receiving the best possible care.