Podcast: For-profit long-term care homes and the risk of COVID-19
Transcript
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Kirsten Patrick: As COVID-19 took hold in Canada, long term care homes became the epicenter of our pandemic. More than 80% of COVID-19 deaths in Canada has been among the residents of these homes. Why is that? It's no secret that the system is broken and has been broken for a long time, and perhaps closer examination of potential reasons why could help prevent future outbreaks and deaths. I'm Dr. Kirsten Patrick, executive editor for Canadian Medical Association Journal (CMAJ) and today I'm talking to Drs. Nathan Stall and Andrew Costa. They've co-authored a research article looking at the risk of outbreaks and deaths in long term care homes by for-profit or not-for-profit status. They've joined me to discuss their research. Welcome Nathan and Andrew.
Andrew Costa: Good to be here.
Nathan Stall: Thanks for having us.
Kirsten Patrick: Thanks for joining me today. So let's begin, Nathan and Andrew, by having you tell our listeners who you are and what you do.
Andrew Costa: I'm Andrew Costa, I'm an associate professor and hold a Research Chair in clinical epidemiology and aging at McMaster University, and that's in Hamilton, Ontario. I also serve in the capacity of a research director within McMaster and the St. Joseph's health system. And I conduct observational experimental research on models of care and a number of sectors including long term care.
Nathan Stall: I'm Nathan Stall, I am a geriatrician at Mount Sinai Hospital in Toronto. And I'm also a research fellow at Women's College Research Institute and the University of Toronto, both obviously situated in Toronto. And finally, I should note that I am an associate editor for the Canadian Medical Association Journal.
Kirsten Patrick: Thanks to both of you. So it is always important for us to mention that Nathan is an associate editor with CMAJ and he has not been involved at all with the processing or review of this paper. So tell me in summary, Nathan, what you looked at in this research study?
Nathan Stall: Yeah, so we conducted a retrospective cohort study of all the long term care homes in the province of Ontario, covering the period of the largest outbreaks and number of deaths in the province. So that was from March 29, 2020, the first recorded outbreak in the province of Ontario and covering up to May 20, 2020. And what we were looking for was the association between for-profit status of long term care homes and the risk of a COVID-19 outbreak, the risk of the size of the COVID-19 outbreak, so the number of cases of residents in the home infected with COVID-19, and then the number of COVID-19 resident deaths within a home. And so we looked at those three associations again, by for-profit status.
Kirsten Patrick: Andrew, tell me, why did you decide to hone in on this comparison between profit versus not-for-profit institutions.
Andrew Costa: For us as the pandemic emerged, we were very concerned about the vulnerable state of long term care. And those of us who work in long term care or do research in long term care, we absolutely expected a major impact. We're very concerned about how it would unfold. As the pandemic unfolded, the for-profit, not-for-profit debate emerged as a major focus in the media. And we were a little bit frustrated by the crude analysis that was being conducted to, I guess, illuminate that issue, and that it was occurring a little bit to the expense of other issues that we and others understand exist in the sector. Basically, that simple solutions are being proposed for rather complex issues. So we decided that we would investigate the for-profit status issue, not only to answer the question, you know, does it matter? But also examine it in light of a fuller picture. So we were answering the for-profit question as a primary exposure of interest, because it was the major issue in the public interest at the time, but also putting it in context with other factors that we could account for.
Nathan Stall: The other thing I would add, Andrew, is that, as you know, there's several observational studies some done in Canada and some done across the world that tend to suggest that for-profit long term care homes deliver inferior care across a variety of outcomes. And one of the major outcomes that that's associated with is lower levels and quality of staffing. There is some evidence about higher rates of emergency department visits and acute care, hospital admissions and mortality. And so there was a, in addition to sort of the public discourse that was going on, and continues to go on I would argue around for-profit status, there is, you know, several decades of research, some of it in Canada, that has focused on for-profit status and the quality of care and outcomes for long term care homes.
Kirsten Patrick: Now, in your paper, you look at three different categories of long term care facility: municipal homes, not-for-profit homes and for-profit facilities. So just so that we're all on the same page, can you explain the difference?
Andrew Costa: Yeah, and it's probably first important for those listening to make sure to understand sort of what's common. So, all long term care homes Ontario are regulated by the Ministry of Long Term Care and are typically funded. And so the ministry pays directly to facilities, the costs or stipend costs that are standardized and regulated for nursing and personal care, as well as some recreation programming. And that comes in at around $200 per resident per day, or $6,000 a month. And much of the care is for the staffing and it basically provides a staffing ratio that translates to about 2.7 hours of direct care per day. So that's standard across the board. What's also standard is that, regardless of the model, residents pay a regulated and standardized co-payment that basically funds their room and board, you might say. And this amounts to about 60 to $80 per resident per day, depending on the type of accommodation that they pursue being private versus standard. So they're publicly funded and regulated across the board. Homes operate either as a public municipal, not-for-profit, which could include charitable religious community agency or on a for-profit basis. The major differences are around number one accountability. So beyond being accountable to the Ministry of Health, not-for-profit homes that are accountable to a not-for-profit board, charity, agency, a cultural religious group, municipal homes to the municipal council of the municipality who's operating it, and for-profit, either to the corporate board, in the case of chains, or an owner/operator. There are some differences in funding beyond what the Ministry of Health provides in a co-payment. Oftentimes, the governing bodies of not-for-profit homes and municipalities augment funding to enhance services, either through, essentially, fundraising or through municipal budgets. And it varies the extent to which that occurs, and it's not really well understood. Staffing is also different. Municipal facilities, their staff are municipal staff, which generally means higher salaries, benefits, more full-time stable work. And then between them, there are important nuances that are often missed. So although some not-for-profit homes, they are not-for-profit, some of them and it's unknown exactly how many and to what extent they operate with the support of for-profit subcontractors, either in whole or in part. And for-profit facilities, they operate differently as well. Some are publicly traded companies, whereas others are small single owner operators.
Kirsten Patrick: You looked at odds of COVID-19 outbreak in relationship to category of home and the extent of the outbreak and deaths from COVID-19 if there was an outbreak. So can you first tell us about outbreaks and what you found?
Nathan Stall: Yeah, so in our analysis what we found was that the odds of a COVID-19 long term care home outbreak was not associated with the for-profit status of the home, but rather was associated with the incidence of COVID-19 in the region, the public health unit region, surrounding a long term care home. It was also associated with the number of residents that were in a home and it was associated with older design standards. So older standards that the long term care home are held to in terms of the physical infrastructure of the building. And, you know, to us that that suggests that, you know, when we talk about an outbreak in a long term care home during the during the pandemic, most of these homes became relatively closed environments, meaning that there was a ban, a blanket ban on visitors. Many of these homes, people were only leaving the homes to go to acute care hospitals. New admissions were not happening. And so, what was happening was the vector, and this has been shown in other studies, was the staff that were coming from the community and unknowingly bringing virus into the home. And that's reflected in the fact that the incidence of COVID-19 in the region surrounding the nursing home was more responsible for seeing the outbreaks rather than the for-profit status of the home itself.
Kirsten Patrick: So as well as the risk of an outbreak in a care home, can you tell us about the size of an outbreak in relation to for-profit status?
Nathan Stall: Yeah, so here's where we found a significant association between for-profit status and the extent size of an outbreak or the number of residents that got infected with COVID-19 in a home that had an outbreak. And when we looked at the data, we found that for-profit status was associated with a nearly two fold increase in the size of COVID-19 nursing home outbreaks. And when we actually did an explanatory model to look at what might be the factors that could explain that, what we found was that older design standards was a significant factor and also chain ownership of the long term care home was, as well.
Kirsten Patrick: And what about deaths?
Nathan Stall: Yeah, so similarily, for-profit status was associated with a 1.78 fold increase in the number of COVID resident deaths in for-profit homes, as compared to not-for-profit homes. And again, in our fully adjusted explanatory model, the number of guests again, seem to be mediated by homes with older design standards, and chain ownership of the homes. What's important to note for both the association between for-profit status, and its association with the size of nursing home outbreaks and the number of deaths within nursing homes, was that all these comparisons favored municipal homes even more. So it seemed that municipal homes did the best of the three profit categories we looked at. Nonprofit homes were in the middle and then for-profit homes had fared the worst for these three outcomes.
Kirsten Patrick: That's very compelling. So Nathan, you were talking about some design standards. And I wondered if you could give us a little bit of background about what that is, I know that there were different design standards mandated at a certain time. What are all the design standards or newer design standards for homes?
Nathan Stall: So this has really come up also in the public discourse recently because I think people have been very surprised to know that a substantial proportion of long term care home beds in the province of Ontario actually meet design standards for the year 1972. So we're looking at, you know, nearly 50 year old design standards.
Andrew Costa: The older long term care homes that we classify essentially conform to a standard that was introduced in common 1972 with the original Nursing Homes Act. And back then it was quite common that you would have across the board institutional designs where there's a lack of common areas, they use four bed ward type rooms. And the way we viewed long term care then especially was as institutions, and not as home-like living spaces. That's evolved over the years and there's been successively improved standards, up until about 2009 and 2015, where there was the mandate that facilities would be built in a more home-like way. This meant that there was a complete elimination of four bed ward style rooms. They were larger rooms, you could have only a maximum of two individuals per bedroom, they instituted a rule that provided for a maximum of, depending on the standard conformity, 32 to 42 beds or residents, excuse me, per home area, which is essentially a self-contained unit within a facility that has its own self-contained eating areas, kitchen, recreation space, such that residents could feel like they're in a more home-like environment. And so beyond quality of life, this obviously has advantages for infection control. In those facilities, they could manage their workforce such that they would be assigned to one of those unit areas, so that outbreaks if they occurred could be contained in those unit areas much easier. Whereas in those institutional environments, not only is spread much easier because of the crowding within rooms, but also across the entire facility.
Kirsten Patrick: Is this a situation of those older designs are grandfathered so the operations can continue within those older homes, because they were built before a certain time but new builds have to comply with the new standards?
Andrew Costa: Yeah that's correct. And it's also complicated by the nature in which the facilities operate. To the extent that if facilities are municipal, then there are advantages with capital funding from the municipal government to be able to upgrade facilities where you have, in particular, owner-operated facilities, oftentimes there isn't the capital budget or perhaps the willingness to upgrade their facilities. And it's a complicated issue, because the government stipend provides some incentive towards upgrading your facility, but not enough that financially in a for-profit scenario, you would necessarily think it's worth your while.
Nathan Stall: The other thing, which has come into the news also recently is that not only is there a commitment to building new beds from the government of Ontario but there's a commitment as well to upgrading beds. And so they've recognized that these beds with the older design standards, the technical term being the C and D type beds, they have also targeted these for upgrading. Now that the question of why these haven't been upgraded, the actual term of the license that is given to these beds is a lot lower, and there was the expectation, and there has been expectations for homes, that they would upgrade these older beds as licenses expired. But as Andrew said, this is a quite complex issue. And so licenses would expire and they seem to keep renewing these licenses without having upgraded. They keep renewing them with short-term licenses and there has been no way to actually force them to upgrade these beds.
Andrew Costa: The Ministry of Health is in a tough spot to the extent that they do not renew the licenses, they reduce capacity in a sector that is already overstretched, which is viewed as undesirable on behalf of the entire health system, including hospitals that are dealing with an alternate level of care (ALC) continued crisis. And so where there isn't willingness to upgrade the facility, it tends to persist rather than close or some magical financial incentive to emerge that they would upgrade.
Nathan Stall: So the majority of homes with older design standards are for-profit. And pessimistically one could look at it that, you know, they know that there is incredible demand, they have seen that there's no consequence for a failure to upgrade, and so this issue persists. And their licenses keep getting renewed.
Kirsten Patrick: And any reason that if homes are a private chain, there might be an increase in likelihood of people dying once an outbreak starts?
Andrew Costa: This was a curious finding for us. And we think it needs more investigation. There was a good bit of variation in the association which also leads to a little bit of confusion around our hypotheses for but we think it may, as supported by the literature, due to lower staffing levels, but more likely more part-time staff and more instability in their staffing base associated with chain ownership, which is generally associated with for-profit publicly traded companies. And if this was to be true, and obviously requires more investigation, it would be yet another powerful example as staffing mix and dynamic has a very powerful mediator for quality.
Kirsten Patrick: I think it's actually important to focus on that issue of staffing because you were not able to look very closely at staffing in this study because you looked at the facility level. So could you tell us about sort of the limitations around that that made it not possible for you to look at staffing?
Andrew Costa: Staffing was certainly a limitation for us and limitation associated with two things. Number one, we have very poor information on staffing dynamics, because it's just generally not collected. And number two, if we had better information, it would be of little utility because at the time before the pandemic, the staffing situation would have changed radically with the pandemic where there was directives around staff not being able to work across facilities, which meant that there was a huge shift in the workforce that we probably can't account for.
Nathan Stall: The other thing that I was just going to add to that is that it actually also speaks to, you know, the data that we had available for analysis is from the Ministry of Long Term Care and the staffing data that they have reflects the number of full-time equivalent staff per resident in the home. What we don't know and what this doesn't capture, because that just talks speaks about the entire number of rostered staff, it doesn't actually talk about the number number of hours that staff physically spends in the building, which is clearly a much more important indicator. And I think hopefully, as we'll talk about, in this sort of conversation about long term care homes and how we can improve things, I think there needs to be much greater attention to this issue of staffing and also to having a better understanding of those actually direct care hours that residents actually have from the staff members. And that was really what, you know, what we were unable to do in our analysis, but I also think it speaks to the data that's in front of the decision makers that they also do not have.
Kirsten Patrick: Interestingly, the commentary linked to your paper explores some of the limited evidence that there is from other jurisdictions around staffing and their patterns of staffing and how that's associated with safety on the whole and COVID-19 dynamics in particular. Speaking of other jurisdictions, do you suspect we'd find the same results in other provinces in Canada?
Nathan Stall: It's a good question. You know, when you actually look at what happened to long term care homes across the country, only two provinces really saw the catastrophe in our homes, and that's the province of Ontario, which had just over 2700 deaths, and Quebec, which has over 5600 deaths. The next highest number of deaths is British Columbia, which is about 189 with only 39 homes affected. So I suspect, given what we found, and given the known association between for-profit status and overall lower qualities of care, that we'd probably see this in a province like Quebec, but we'd be underpowered to detect this in other provinces across the country because thankfully, their homes did not have the, you know, the really devastating outbreaks that Ontario and Quebec saw. There's many reasons why other provinces had differences in, you know, in the outcomes that we saw in long term care homes. Let's take British Columbia, which has gotten a lot of attention in a good way for the work that Bonnie Henry and their public health agency has done. There are a lot of things that they did early on, which differentiated themselves from provinces like Quebec and Ontario. The province actually took over as employers of their long term care home staff, to enable them to work at one home to provide them full-time pay and benefits. They did that quite early on in the pandemic, and specifically, when long term care homes were impacted. The other thing that they did, and that we know they did was that they tested early and broadly within their long term care homes and within their long term care home staff. And in a province like Ontario, testing early on in the pandemic was very restricted. And additionally, there was a reliance on testing residents that had what are called the typical symptoms of COVID-19: the fever and the cough. We actually know that about three in four long term care home residents don't actually mount a fever when they have COVID-19. And they're more likely, like all other infections in older adults, to have atypical signs and symptoms, whether it's falls or delirium. So a lot of cases of COVID-19 were likely missed earlier on in the pandemic because of testing requirements that tied it to having those typical symptoms. And then, frankly, Quebec and Ontario, which is most pertinent to our analysis, are provinces that actually have some of the oldest design standards for our long term care homes in the country. And so I think a combination of all these factors was likely to explain it. And then also, as we saw in our analysis, the COVID-19 incidence in the communities in Ontario and Quebec, I mean, these were the two hotspots of the country for COVID-19. And so, you know, we showed that the risk of an outbreak in a long term care home was associated with the incidence of COVID-19 in the community. So it follows that they're gonna have an easier time seeding your nursing homes to have outbreaks when you have higher community incidence of COVID-19. So there are many factors at play here. But you know, to come back to your earlier question about would we see this in in the same results in other provinces or not? You know, it's, it's a little bit like comparing apples to oranges. And I think that, you know, we often strive for national analyses, but sometimes when we're dealing with so many complexities within the long term care system like this, there were many things that were going on that make direct comparisons challenging. And the final point I'll make to this is that the Canadian Institute for Health Information actually released a report at the end of June exploring how Canada compares with other countries in terms of our long term care response. And, again, I've already highlighted the caveats of direct comparisons, but Canada was compared to 16 other Organisation for Economic Co-operation and Development (OECD) countries and what they found was that Canada, we have the dubious distinction, or as I call our national shame of having the highest proportion of our country's COVID-19 deaths occurring in long term care homes, which you highlighted up front as somewhere around 80%. And what they they showed here is that countries who actually implemented strict and early measures to try and prevent and contain long term care home specifically, when they did that at the same time as measures they implemented for the broader population, so things like stay-at-home orders and closure in public places, countries like Australia and Austria, the Netherlands that did this at the same time, actually had much better outcomes in their long term care sector. And so if you look at a province like Ontario a lot of the state of emergency that was declared and closure of public spaces happened in mid-March, it took until mid-April to actually enable staff to work at one home and not have them traveling between homes. It took much longer to pursue universal masking and to secure the access to personal protective equipment and diagnostic testing that was needed in this vulnerable population. And I think that's reflected in the fact that Canada did do worse when it came to our long term care sector.
Kirsten Patrick: To come back to your direct findings in your study, do you think that based on what you found we need to move away from for-profit long term care homes in Canada?
Andrew Costa: It's an active public policy debate. And our study, curiously, has been cited for both sides of the argument. And we're consistent with previous studies that have found small, but rather inconsistent associations between for-profit status and unfavorable outcomes. And the consistency of those associations supports the view that we should eliminate for-profit long term care homes. The inconsistency supports the alternative view and so the debate rages. I guess it's on its face, it's important to know that it could be a slightly intractable issue. And so it's important to recognize that about 60% of facilities in Ontario are for-profit, and of those 26% that are not-for-profit an unknown but meaningful number of them are actually operated by for-profit providers as subcontractors. And so with municipalities, as I understand not exactly lining up to open up more long term care homes, our situation to move away from it is very challenging, because it obviously would be a huge change. Whether that's desirable or not can continued to be debated on both sides. It's important to know that the relative differences exist, but there are fundamental absolute differences that need to be tackled. And so if you were to take out for-profit, you're still left with some pretty big issues of a general lack of staff funding, poor wage standards, poor training, ages and isolation of the sectors. And so these are modifiable factors that we point to in our analyses, for instance. What has been immediately addressed and will continue to we certainly hope was to finally get on the work of improving the plant of these facilities. So going beyond these 1972 design standards to the kinds of facilities that we would hope that one day we could live in, in fact that they would be better one day. We really need to fix the older facilities and upgrade them immediately and not allow any resident to enter in a facility that isn't upgraded. That's really important. It's something that we could do now. The other is the staff issue, which, which we've now mentioned, again. I don't know anybody that thinks that about two and a half hours of direct care per resident per day is at all sufficient. And in a highly regulated sector like long term care, you'll see differences in that ratio in municipal facilities compared to for-profit facilities, for example, but it is not huge. It's meaningful, but it's not huge. And so governments really need to make a substantial financial commitment to ensuring that there is adequate staff time across the board regardless of facility and ensure that any additional funding is translated into actual direct hours of care and not for other things.
Nathan Stall: The other thing I'll add, Andrew, related to our findings and was the impetus again for our study, was that what we found was of the homes that had the highest infection rates, 13 of the 15 homes with highest infection rates were for-profit homes with older design standards. And similarly, when we looked at homes, the 10 homes with the highest COVID-19 death rates, seven were for-profit homes again with older design standards. And so, you know, in this conversation about let's get for-profit out of the sector, analyses like ours are essential to show that, you know, not everyone is a bad actor here in the for-profit sector and there is a philosophical argument to be had about how people feel about having a for-profit entity within our long term care sector. That's not what we explored here. We explored objectively and scientifically was it all long term care homes and what were the factors of those long term care homes? And so, as we engage in these conversations in the public and governments contemplate these results, it's important to note that it's the for-profit homes with those older design standards. And that's something we can target, as we head into anticipated successive waves of this pandemic. And also, recognizing the COVID-19 is not the only risk to older adults lives, that there are other infectious outbreaks that occur every year within long term care homes, most notably influenza. And so something like targeting older design standards, the majority of homes that have these tend to be for-profit, but to paint the whole sector as saying all for-profit homes failed is somewhat disingenuous. And that's, I think, what's quite important about our analysis.
Kirsten Patrick: And underneath all of this, I guess, is the bigger picture that this problem of long term care is not going away, we have an aging population, the demand for beds and more spaces is going to increase. And we have to work with what we've got. So in your opinion, you've alluded a little bit to this already, in other countries that have similar demographics to ours and where COVID-19 has been a bigger issue, like Italy, for example, why did long term care not become the epicenter of the COVID-19 pandemic?
Nathan Stall: Had we become in Canada or had parts of our country become overrun like New York City or Bergamo, Italy I don't think we'd be talking about this. Because quite frankly, there would have been deaths that the media and that society would have been more interested in focusing on than nursing home resident deaths. But the truth is, we actually did quite a good job in Canada, of containing the deaths and the number of cases within our community during the first part of this pandemic as we've spoken about at the expense of our long term care sector. So there are countries, like the United States would be a prime example, which have had far more deaths occurring in long term care homes, in fact, they can't even calculate the number of deaths within their long term care homes and no one even knows at this point in time as we record this on July 17, 2020, what's the exact number of deaths that have occurred, but the focus has all been on the community, because there have been settings like New York City, and there have been settings across the country and there continue to be as the cases at this point in time are exponentially growing. There are hospitals that are becoming overrun. So that hasn't been as much of a focus. But I think we've really got to shine a light on a sector that has been so neglected, which is our long term care sector.
Kirsten Patrick: In a CMAJ editorial by Jayna Holroyd-Leduc and Andreas Laupacis, they discussed how the public health response in long term care homes in Canada was sort of almost an afterthought like it wasn't joined up with the public health response in the broader community and that kind of resonates with what you're saying. I think public health might come back and say, well, we tried our best, but resources were limited, but it definitely is something to think about in the future.
Nathan Stall: I think so too. There was a very nice viewpoint in JAMA, authored by Scott Halpern. Who's at the University of Pennsylvania (UPenn). And he talked about some of the cognitive biases in public health policy during COVID-19. And one of the things he he talked about as thwarting effective policy during this crisis is what they referred to as identifiable victim bias. And so humans tend to respond more aggressively to threats to identifiable lives, those that they can imagine being their own or belonging to people they care about. And so I think people do not identify with long term care home residents. They experience the double discrimination of having age related stigma and also dementia related stigma. And what people were very fearful of when we plan for this pandemic were scenes, like Bergamo, Italy or New York City of overrunning our critical care system and our hospitals and young people on ventilators. And you're absolutely right in that long term care home residents were an afterthought. And that's reflected in the results that we have to show here and again what I call our national shame.
Andrew Costa: It's really important to understand that although in Canada, we have the dubious distinction of having the highest proportion of deaths occurring in long term care that we are aware of amongst the OECD countries, our overall mortality rate was essentially the middle of the pack, compared to all other OECD countries where Belgium and Spain were understood to be very high, and Australia and Norway on the lower end. We are right in the middle or very close to the United States as well as Portugal.
Nathan Stall: In terms of our long term care home population mortality rate from COVID-19, not our overall mortality rate.
Kirsten Patrick: We stand out as having our highest proportion of deaths within the long term care sector of overall deaths, but other countries have had much, much, much higher death rates, and therefore their long term care facilities proportions look smaller.
Nathan Stall: Yes.
Kirsten Patrick: Interesting, what you were saying about some undercounting of how the long term care sector is affected in other countries. I believe that's the case in the UK as well, this sort of obfuscating of data around long term care deaths. And it was almost like we all tried to empty our hospitals to create capacity for COVID-19 potential cases. I believe that in the UK hospitals got emptied out into long term care facilities, possibly creating a situation where there was an increased risk of COVID-19 in those facilities. So it's almost like we're owning our shame a little bit more than other countries are.
Nathan Stall: We may be owning it but now we have to act on it.
Kirsten Patrick: Exactly. Moving on to sum things, up as two experts in the field what do you think needs to happen in the short term, and then in the longer term with how we can care for older adults in long term care facilities in Canada?
Andrew Costa: For the short term, I think we need to continue on the path of upgrading facilities, these older facilities that are problematic, such that in subsequent waves that might occur, we can lower the risk of the kinds of infection spread that we saw originally. Essentially, that means capital funding to improve these facilities immediately. And to deal with some of the issues that have been brought to bear. For instance, the lack of air conditioning and some facilities, which is a complete embarrassment, I think, I think it's untenable in Canada that we would have that be the case. The second issue is to immediately increase the subsidy levels such that adequate staffing can be provided, regardless of facility type for-profit, municipal, or not-for-profit. These are immediate short term changes. In the long term, this debate of for-profit, and not-for-profit versus municipal is a symptom of a larger problem, which is that we have not in Canada conceptualized seniors care, including home care and long term care within the Canada Health Act. And we have various models and intractable issues that have developed as a result. We really need to think about how those sectors fit within the Canada Health Act, having national standards for those sectors, as well as how that works with a realistic and real national dementia strategy is really important.
Nathan Stall: I would absolutely echo what Andrew is saying. I think in the in the short term because of the fact that much of the discourse around long term care is now shifting to looking for accountability and trying to fix the system, which is a good thing, we also have to recognize, and not to fear monger. But I think this is something you know, the prudent healthcare systems in Canada are planning furiously for a second wave, which could happen in a matter of weeks, and there are many things that need to be addressed immediately that are not going to be addressed by the longer term changes of building new beds and upgrading existing ones. Those need to be done and it shouldn't be one at the expense of the other. They need to be done together. So specifically right now, in addition to bolstering staffing and securing fair wages with benefits for staff members, which I think is, as Andrew says is an utmost priority, and that's supported by also the recent Royal Society report that came out just earlier this month. There are still ongoing issues in homes when it relates to having enough infection prevention and control support and expertise. There homes that continue to report having personal protective equipment shortages. These homes are in need of not just increased staffing to care for the residents, but increased staffing that comes with all the extra protocols and procedures that are necessary to prevent COVID-19 from entering in our homes. We've experienced also not only an epidemic of COVID-19 that has ravaged through our homes, but the residents within these homes have also experienced substantial collateral damages because of the restrictions that we've needed to input into these homes to prevent COVID-19. So many of these residents, we haven't found a way to reintegrate their family caregivers or to reintegrate family to provide them with social interaction. So there's huge rates, anecdotally, but certainly things that I've seen clinically and they've been echoed from colleagues around the world, of loneliness and social isolation. Residents have, like all other members of society, but perhaps the effects have been most exacerbated in this population have not had medical care to the same intensity or frequency they would have beforehand. So there has been physical declines, functional declines, cognitive declines, there are huge issues that are ongoing right now that needs to be sorted out in terms of how are we going to prevent ongoing collateral damages from occurring and how do we mitigate that from happening if we need to clamp down on homes, again, if COVID-19 should roars again in our community and then ultimately end up in our long term care homes? One of the things that's important, and comes out of findings like ours is that homes across the province of Ontario have actually made a public health order from the Chief Medical Officer of Health's office to no longer have new admissions to four person rooms. That reflects the fact that we saw that when you actually have crowding in a long term care home like we saw in our analysis the older design standards that have these multi occupancy rooms led to the larger and deadlier outbreaks. So that is a good public health intervention that has come out of findings such as ours. The obvious counter to that is that now we've created across our province, we estimate about a 10,000 bed deficit in long term care. So one of the things we also immediately need to do is invest in Home and Community Care for the 1000s of people in our province, who already had a limited access to Home and Community Care. But now we're in crisis, and we'll be waiting longer for long term care, because of the changes that we've made, which are important, and, you know, for rethinking public health changes, but are clearly a result of a failure to upgrade those those older homes with the older design standards. So I think that's also very important to note and you know, that public health policy has actually come out of findings such as ours, which is, which is very important. So there are there are many issues that immediately need to be dealt with that should also be a focus in addition to the broader issues of for-profit status of upgrading homes, building a long term care sector where you know, we that feels like a home and that we would want our loved ones to enter. We need to make sure that many of the things that happened in response to the crisis in long term care homes like acute care sector partnerships, where we shared human resources and expertise and personal protective equipments, that some of these relationships are fostered so that we no longer leave homes like we did to fend for themselves, resulting in dramatic measures, like needing to call on the army and catastrophic death rates. That should never happen again. And so, you know, we need to remain extremely vigilant across our country, and we need to keep this sector at the forefront of public discourse and planning for successive waves of this pandemic.
Kirsten Patrick: Thanks, Nathan. Well, it's been fantastic to have this in depth discussion with two such passionate experts in this field. Thank you so much for taking the time to join me today.
Andrew Costa: My pleasure.
Nathan Stall: Thanks so much for having us.
Kirsten Patrick: I've been speaking with Dr. Nathan Stall and Dr. Andrew Costa. To read the article they co-authored visit cmaj.ca. Also, don't forget to subscribe to CMAJ podcasts on Soundcloud or a podcast app and let us know how we're doing by leaving a rating. I'm Dr. Kirsten Patrick, executive editor for CMAJ. Thank you for listening.