Long-Term Care COVID-19 Commission report receives thumbs up from RNAO; Will government act?

The Ontario government owes an apology to the families of the 3,758 long-term care (LTC) residents lost to COVID-19 and to the staff that valiantly cared for them under deplorable conditions – including 11 who lost their own lives in the line of duty.

Residents of LTC homes deserve the dignity of safe and quality care. The recommendations released Friday by the Long-Term Care COVID-19 Commission provide pointed directions for the government to meet its obligations. Nurses call on the government to enshrine in legislation and immediately implement the urgent staffing and skill mix recommendations; Infection Prevention and Control imperatives, and the needs of residents and their essential care partners.

Those are the overarching messages from the Registered Nurses' Association of Ontario (RNAO). The failings outlined in the commission's report echo systemic issues the association has raised for over two decades, including since 2018 with the Ford government.

RNAO issued early warnings in February 2020 in view of the unfolding catastrophe in Italy. It called on the government to adopt the precautionary principle and to take measures to protect residents in LTC. Despite these warnings, the virus swept through hundreds of homes claiming 3,758 lives, most of them during the first and second waves of the pandemic.

The independent commission, led by Associate Chief Justice Frank Marrocco, outlines recommendations on chronic underfunding of the sector, severe staffing shortfalls and infection control deficiencies. These priorities must be addressed to prevent another horrific tragedy.

Among the commission's recommendations:

• The adoption of the precautionary principle "as a guiding principle throughout Ontario's health, public and worker safety systems" (Recommendation 2)
• Ensuring that staff are supported so that they do not – for financial reasons – attend work while sick (Recommendation 9b.)
• Staffing nursing homes to four worked hours of direct care per resident, per day (Recommendation 44)
• A skill mix that includes 20 per cent of staff comprised of RNs (48 minutes of direct care per day), 25 per cent RPNs (60 minutes of direct care per day), and 55 per cent personal support workers (132 minutes of direct care per day) (Recommendation 44)
• One NP for every 120 residents (Recommendation 46)
• One full-time RN per 120 beds dedicated as the Infection Prevention and Control practitioner(s) reporting directly to the Director of Care (Recommendation 24a)
• A call for minimum possible restrictions on visits of essential caregivers to LTC residents (Recommendations 5d, 30, 31, 32)
• Increase funding and shift to a funding formula that augments case mix index (CMI) with recognition and rewarding of quality outcomes and person-centred models of care (Recommendations 56, 57 and 58)
• Increase funding for home care services to enable aging at home, whenever possible (Recommendation 59)
• Ensure Ontario Health Teams include LTC homes as part of the continuum of care (Recommendation 28)
• Annual comprehensive Resident Quality Inspections (RQIs) (Recommendation 67a)
• Strengthening of whistleblower protections for Health Protection and Promotion Act investigations (Recommendation 81)

While the government has already pledged to introduce four worked hours of direct nursing and personal care for residents, it is not taking meaningful action. The commission's report reinforces RNAO's call for an accelerated process to increase staffing and achieve the required skill mix endorsed by the commission for safe and dignified care. There has been plenty of time to plan and implement. The same demand for staffing and skill mix urged by the commission was outlined in RNAO's Mind the Safety Gap report in 2016 and consistently thereafter including in the association's Nursing Home Basic Care Guarantee submitted to Minister Merrilee Fullerton in 2020.

The commission endorsed a recommendation made by Justice Eileen Gillese in her 2019 public inquiry report into LTC. It called on the Ministry of Long-Term Care to "encourage, recognize, and financially reward long-term care homes that have demonstrated improvements in the wellness and quality of life of their residents" (Recommendation 57). RNAO has communicated this concern repeatedly to governments, past and present. Ministry funding is cut when best practices are implemented that improve resident outcomes and lower acuity, since funding is only tied to resident acuity levels measured by CMI. "Homes that implement RNAO's best practice guidelines and are designated as Best Practice Spotlight Organizations should not be penalized for raising the quality of care among residents and improving health and clinical outcomes, which in turn reduce their acuity," says Dr. Doris Grinspun, RNAO's CEO. 

RNAO applauds the commission's recommendation that 70 per cent of staff be full-time (Recommendation 49), a call made by RNAO two decades ago. "Precarious work has plagued the LTC sector. Full-time work contributes to better health outcomes as staff get to know their residents and develop meaningful relationships that result in resident-centred care. Providing full-time, stable work means staff members also have security and are not forced to work multiple part-time or casual jobs, moving between homes and increasing risk of infections," says Grinspun.

RNAO is delighted with the recommendation to increase funding for home care services to enable aging at home, as well as for long-term care homes to be included in Ontario Health Teams. RNAO raised these issues in its Enhancing Community Care for Ontarians (ECCO 3.0) report released in 2020 decrying that community care and LTC have been left out of consecutive governments' health transformation agendas – a reality exacerbated during the pandemic.

"The catastrophe in LTC began in the first wave. In a move that prioritized hospitals, the needs of residents were ignored and ultimately sacrificed by the government. LTC homes didn't have personal protective equipment, severe staffing issues were not addressed and the government delayed measures to control the spread of the virus," says Grinspun. She adds this was "a tragedy that will haunt us for years to come. It was shameful, reckless, and completely preventable had this government acted in time – as advised by RNAO and other experts. Ultimately, when the government finally followed that expert advice, we stopped the devastation in nursing homes."

"We will watch to see how serious the government will regard the commission's report. The government called for this commission and should act on it immediately. Although Premier Ford and his team did not start the fire in nursing homes, they allowed it to engulf them. They now have an enormous opportunity to change course and bring about transformational change in LTC. The government can carve a new path for the sector and create a better future for residents," says Morgan Hoffarth, RNAO's president.

"We thank Justice Marrocco and his co-commissioners for their in-depth work and for highlighting critical issues and urging government to act. They recognized the ferocity of the pandemic and issued two sets of interim recommendations in advance of their final report. We thank them for listening to residents, families, LTC staff, stakeholders and experts. It's clear they were deeply affected by what they heard and learned and we are indebted to them," says Hoffarth.

RNAO says the fate of residents in Ontario LTC homes is once again in the hands of the province. Will the premier accept all the recommendations and act on them expeditiously? Or will the commission's report sit on a shelf along with the other 35 reports, a previous public inquiry and coroner's inquest spanning 20 years? Justice Marrocco's report details clearly the staffing and resources required to enable safe care and dignified lives for residents. The time for government action is long overdue.

The Registered Nurses' Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses' contribution to shaping the health system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit RNAO.ca or follow us on Facebook  and Twitter.

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