Long-Term Care COVID-19 Commission: final report and progress on interim recommendations
Response to Long-Term Care COVID‑19 Commission interim recommendations
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The Ontario government launched the Long-Term Care COVID‑19 Commission to investigate:
- the spread of COVID‑19 within long-term care homes
- how residents, staff, and families were impacted
- the adequacy of measures taken by the province and other parties to prevent, isolate and contain the virus
This page outlines the governments response to and progress on the commission’s guidance and recommendations into their two interim reports on how to better protect long-term care home residents and staff from any outbreaks in the future.
- In addition to increasing the supply of personal support workers, ensure that long-term care staff recruitment efforts address the requirement for an appropriate staff mix to meet the increasing acuity and complex care needs of residents.
- While all witnesses agreed on the need for staffing flexibility given the 24/7 nature of homes’ operations, more full-time positions must be created to ensure staffing stability and retention, and resident continuity of care.
- Beyond these initial steps, identify the permanent investments required to develop and implement a comprehensive human resources strategy that addresses the full range of staffing issues in the sector. The ministry’s Long-Term Care Staffing Study, released in July 2020, identifies the best path forward. Further “study” of the study is not necessary. What is required is the study’s timely implementation.
- Consistent with that study, the Commission recommends a minimum daily average of four hours of direct care per resident. The government needs to increase permanent funding for more nurses and support staff, to enable homes to increase their staff to resident ratio, and provide more hours of care, based on residents’ needs.
- Given the essential role of families and caregivers in supporting not just physical care needs but the psycho-social well-being of residents, we reinforce the calls from residents, families and caregivers to ensure that families and caregivers have ongoing, safe and managed access to long-term care residents.
- Staffing is critical in ensuring safe and quality care for long-term care home residents, including an appropriate mix of staff roles to address residents’ complex needs.
- Ontario is addressing longer-term staffing challenges. In December 2020, the government launched A Better Place to Live, A Better Place to Work: Ontario’s Long-Term Care Staffing Plan, which sets targets to fulfill the province’s commitment of providing an average of four hours of direct daily care to residents by 2024-2025. These are:
- increasing staffing levels
- disrupting, accelerating and increasing education and training pathways
- supporting ongoing staff development
- improving working conditions
- providing effective and accountable leadership
- measuring success
- Ontario is investing up to $1.9 billion annually by 2024–2025, or $4.9 billion over the next four years, to support this plan. This funding will also support a 20% increase in direct care time by allied health professionals such as physiotherapists and social workers.
- On September 28, 2020, the government announced an investment of $52.5 million to recruit, retain and support more health care workers in the province.
- This includes an investment of $26.3 million to support the recruitment, training and retention of personal support workers and other unregulated health professionals, a new personal support worker Return of Service program, training for supportive care workers and accelerated personal support worker certification for those with prior health care experience.
- It also includes an investment of $26 million targeted at increasing recruitment of nurses: Ontario’s Nursing Graduate Guarantee program and funding to increase nursing positions in areas of high need.
- The government also announced $461 million to temporarily enhance wages for personal support workers across various sectors. This includes a $3 per hour increase for approximately 50,000 eligible workers in long-term care, originally intended to be in place from October 1, 2020 to March 31, 2021 and recently extended to June 30, 2021 with an additional $239 million investment.
- The government has also continued to provide prevention and containment funding to all long-term care homes to assist them with the incremental costs associated with responding to COVID‑19. This includes the ability to use funds to support more full-time shifts, particularly in response to the single-employer requirements for long-term care staff.
- Work is underway to expand education and training programs to train the tens of thousands of new staff that will be required. Early investments include more than $115 million to train nearly 8,200 personal support workers through public career colleges, and $86 million to train up to 8,000 personal support workers through district school boards and Ontario Student Assistance Program approved private career colleges.
- The government has also established the Staffing Supply Accelerator Group to champion innovation in training and education for long-term care staff, including personal support workers, registered practical nurses and registered nurses.
- As the government makes significant investments to increase staffing levels, sector partners need to help lead change in critical areas. While the province recognizes the scheduling challenges of a 24/7 environment, this change must include exploring and sharing best practices to increase full-time positions and employee retention.
- As an initial focus, the ministry is working with Ontario Long-Term Care Association and AdvantAge Ontario, who will lead a working group to identify opportunities, best practices and potential barriers to enhance scheduling methods and increase full-time positions.
- The government will also work with our sector partners, including employers, associations and unions, to further address working condition issues.
- Ontario developed training materials for infection prevention and control to support family members and caregivers provide safe care to their loved ones over the course of the pandemic. The training is available on Public Health Ontario.
- Ontario continues to work with Family Councils Ontario and other partners to identify any additional supports that may be required as the COVID‑19 situation evolves.
- Ontario released an updated visiting policy on September 5, 2020, which provides guidance to long-term care homes to connect caregivers with training, education and resources on protective personal equipment (PPE) and infection prevention and control, so caregivers can care safely for their loved ones.
Strengthen healthcare sector relationships and collaboration
- In the short term, where there are long-term care homes that are likely to have difficulties (whether based on past experience, high infection rates in the surrounding communities or other data), a collaboration model should be mandated immediately. These relationships between long-term care homes, local hospitals and public health units must be based on trust, collaboration and respect on all sides for the expertise all parties bring to the priority of ensuring the health, safety and well-being of residents.
- The Ministry of Long-Term Care to work with the Ministry of Health to formalize these relationships proactively. There is no need to wait until an outbreak has occurred before a local hospital assists or is compelled to assist a long-term care home. Clearly defined supports and surge capacity for each long-term care home must be in place and quickly mobilized when an emergency situation arises.
- The strong partnerships and integrated care established by Ontario Health Teams and Ontario Health have helped Ontario’s health care system to quickly and effectively respond to COVID‑19. This includes:
- supporting long-term care homes
- simplifying the purchase of personal protective equipment, helping establish assessment centres
- launching virtual urgent care initiatives, and expanding remote patient monitoring programs to support COVID‑19 patients and other vulnerable populations
- An Incident Management System that provides rapid advice, direction and action was established to support homes as needed.
- The government ensured that all long-term care homes were connected with hospital partners, to respond quickly in case of an outbreak. This included helping hospitals assume temporary management of long-term care homes, where necessary, to help these homes manage resident care while responding to COVID‑19 outbreaks.
- A specialized care centre was opened on December 28, 2020 to help address the increased demand for COVID‑19 outbreak support to long term-care homes in the following regions:
- Halton Region
- In April 2021, the use of the specialized care centre was expanded to include alternative level of care patients from Toronto and surrounding area hospitals, who are waiting for transfers to long-term care homes. Eighty of the 90 beds are available for long-term care patients who require alternative level of care. The 10 remaining beds are marked for high risk long-term care homes.
Improve infection prevention and control (IPAC) measures
- Ensure every long-term care home has a dedicated IPAC lead who can monitor, evaluate and ensure compliance with proper protocols; support and provide basic training for all staff, and access the local infection prevention and control centre of expertise, as required.
- Enhance long-term care ministry resources and capacity to provide compliance support immediately. In the short term, inspection staff from your ministry and others who can be trained, as well as from the local Public Health Unit, should be sent into homes to conduct timely, focused inspections to ensure homes are properly implementing proactive IPAC measures, and are responding effectively to their assessment results. These inspections should prioritize visits to homes based on the same risk measures as those used for our first recommendation under Relationships and Collaboration section above.
- Given long-term care residents are a highly vulnerable population and to date have suffered the highest COVID‑19 death rates, provide highest priority access to testing and quick turn-around of results for residents and staff. The government should also prioritize long-term care homes for point of care and less invasive tests as they become available.
- Residents who are COVID‑19 positive, especially in older homes, should be given the option to transfer to alternate settings to avoid further transmission of the virus and to help them recover. Given that many long-term care homes cannot effectively cohort and isolate because of physical infrastructure limitations, each home should work with its hospital, public health partners and others to put plans in place to quickly decant residents to other facilities, if it is appropriate and safe to do so. The plan should identify these facilities in advance.
- Ontario’s COVID‑19 Fall Preparedness Plan for Health, Long-Term Care and Education included new investments and actions to help long-term care homes access advice on:
- infection prevention and control
- surveillance measures
- Investments in 2020-2021:
- $786 million to help homes with infection prevention and containment measures, staffing supports and purchasing additional supplies and personal protective equipment
- $61.4 million for repairs and renovations to improve infection prevention and control in homes (such as upgrades to support physical distancing, plumbing or water supply cleaning, updating heating, ventilation, and air conditioning (HVAC) systems, or repairing or replacing furniture and equipment that cannot be fully cleaned)
- $30 million for infection prevention and control staffing, including $20 million to hire up to 150 new staff and $10 million to fund training for new and existing staff.
- Incremental 2021-2022 investments announced in Ontario’s 2021 Budget:
- Approximately $650 million to support the continued COVID‑19 response and recovery in long-term care homes, including prevention and containment measures, and to support homes impacted by changes in occupancy and that are facing COVID‑19 related pressures.
- The government developed IPAC training materials to help staff, family members and caregivers provide safe care to their loved ones. The training is available on Public Health Ontario.
- The government released an IPAC guidance document to the sector in January 2021 which is aligned with current best practice guidance from the Provincial Infectious Diseases Advisory Committee.
- The Ministry of Long-Term Care, Ministry of Health and Ontario Health have established Infection Prevention and Control Hubs provincewide.
- Mandatory infection prevention and control observational checklists are used by long-term care inspectors during all inspections.
- The Canadian Red Cross has been deployed to 32 long-term care homes to help with infection prevention and control and provide surge capacity.
- Ontario is hiring more long-term care consultants and environmental inspectors to guide long-term care inspectors and managers on infection prevention and control measures, housekeeping, maintenance and emergency plans.
- Ontario introduced surveillance testing of staff, caregivers, students and volunteers with requirements set out in the Minister’s Directive: COVID-19 Long-term care home surveillance testing and access to homes.
- Homes can choose one of two options for screening and testing of staff, caregivers, students and volunteers:
- an antigen test at a frequency set out in the COVID‑19 Guidance: Considerations for Antigen Point-of-Care Testing (PDF)
- one polymerase chain reaction (PCR) test and one antigen test on separate days within a seven-day period.
- The ministry is working with long-term care home operators, Ontario Health and the Ministry of Health to support the safe admission and readmission of new and returning residents to homes.
Leadership and accountability in long-term care homes
- Require that there is a clear lead for the quality of care amongst the leadership team of the executive director, director of nursing and personal care, and medical director in each long-term care home. This individual must be on-site each day in a full-time position and be held accountable for resident quality of care, and the province provide the financial resources necessary to effectively support the lead for quality of care in carrying out their role and responsibilities.
- Effective and accountable leadership across long-term care is critical to supporting the staffing plan initiatives, achieving necessary culture change and ensuring residents receive a higher quality of care. As an initial step, the government implemented the third phase of the Attending Nurse Practitioner in Long-Term Care Homes program, which provides annualized funding for up to 15 additional nurse practitioners to the sector.
- Moving forward, the government will work with sector partners to clarify the role of key leadership positions, including administrators and medical directors, and to consider the further need for nurse practitioners. The government will also work with sector partners to improve the training and onboarding that long-term care leaders (medical and otherwise) are required to complete.
- Include performance metrics, such as resident and family satisfaction, staff engagement, staffing levels and supply of personal protective equipment in the long-term care home performance reports.
- Publicly post the home performance reports in a single and centralized location so that the public and other homes can assess and compare homes to one another. This information should be updated more frequently and be presented with the inspection status of each home in a user-friendly manner so that the public can search and access a comprehensive picture of each home’s performance.
- The ministry agrees that performance metrics currently collected and made publicly available are limited in their ability to provide insight into both the overall quality of care and resident quality of life.
- The ministry is evaluating options to develop a new quality framework, and performance measures to guide oversight and quality improvement in long-term care homes.
- The Long-Term Care Performance Report provides indicators over time for each long-term care home and compares them to provincial benchmarks or provincial averages. These were developed in consultation with home operators and advocacy groups such as the Ontario Long Term Care Association, AdvantAge Ontario and Family Councils Ontario.
- Under the Long-Term Care Home Act, 2007 long-term care home licensees are required to survey residents and families at least once every year to measure their satisfaction with the home and the care, services, programs and goods provided. This requirement will be assessed in the development of new performance metrics to measure and report on quality of care in long-term care homes.
- Reintroduce annual resident quality inspections for all long-term care homes and require all reactive inspections occurring during the pandemic to include an IPAC Program review. This will ensure that all long-term care homes receive an IPAC protocol review and assessment and that possible violations are identified whenever there is a Ministry of Long-Term Care inspection in the home during the pandemic.
- Request appropriate funding in the upcoming 2021 provincial Budget to hire and train a new cadre of inspectors to implement the annual resident quality inspections (RQIs) on each long-term care home in the system. These resources are important to address the current need as well as the anticipated demand that will be created with the additional new beds that will be coming on stream in the next two to five years.
- Improve enforcement by prioritizing timely responses to non-compliance with IPAC and plan of care orders.
- Ontario is evaluating the inspection program, including the triaging of complaints and critical incident reports, with the goal to develop an improved, standardized inspection process that aligns with addressing risk in reactive and proactive inspections. This evaluation will include what factors require annual inspections or reviews. In addition, the ministry is:
- developing a new quality framework and performance measures to assess progress and support continuous improvement
- considering the appropriate use of and balance between supportive and compliance-focused mechanisms and tools
- Recruitment of 32 new inspectors is underway.
- Mandatory infection prevention and control observational checklists are used by long-term care inspectors during all inspections.
- Ontario will continue to prioritize follow-up inspections based on risk to residents and will ensure processes are in place to monitor targets to ensure timelines are being met.
- The Office of the Chief Medical Officer of Health, Public Health and Public Health Ontario will provide input into the development and implementation of infection prevention and control policies.