Recommendations from long-term care reports, commissions, and inquiries in Canada

Introduction

The COVID-19 pandemic led to a high proportion of deaths in Canadian long-term care homes (LTCH) compared with those of other developed countries. The proportion of deaths from COVID-19 in LTCH in Canada was 81% compared with a mean of 42% in other Organisation for Economic Cooperation and Development (OECD) countries in the initial months of the pandemic¹. This statistic is surprising since Canada is considered to have a relatively low number of COVID-19 deaths overall². The difference in mortality rate was attributed to pandemic preparedness, integration of services (LTCH, public health and hospitals), funding and resources, daily care hours for residents, and comprehensiveness of inspections³.

During the early months of COVID-19, the media reported a shortage of direct care providers and personal protective equipment (PPE) in Canadian LTCHs, which led to residents suffering from a lack of basic personal care and delays in identifying medical problems⁴. Reduced staffing levels and wage compression in Canada’s LTC sector compelled individuals to work at more than one facility to make a living wage. Working at multiple nursing homes contributed to the spread of COVID-19 infection⁵, and although restricting employment to one facility reduced the number of outbreaks, it also exacerbated pre-existing work force shortages⁶. Furthermore, lower staffing levels and direct care hours are associated with increased rates of infection and hospital admission among residents⁷, with this same trend observed in LTCHs with COVID-19 outbreaks^3,5,8.

In April, the Royal Society of Canada Working Group on Long-Term Care was tasked with reviewing the current state of LTC in the face of COVID-19⁹. Their report found 103 LTC reports, commissions, and inquiries, 80 of which were unique reports based in Canada. The review found recurrent themes of longstanding deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis in LTCHs. Despite the wealth of evidence, policy changes were not made. Instead, new LTC commissions and inquiries are being held in response to the pandemic, only to find the same problems already known from past reports^10–12. Given the number of reports in the past, it would be helpful to know which recommendations were made recurrently. Furthermore, the cost of studying LTC using reports, commissions and inquires in Canada is also not known.

The primary objective of this study was to examine the recurring recommendations over the past 10 years. Our secondary objective was to calculate the total costs of generating all of the LTC reports, commissions, and inquiries in Canada from 1998 to 2020. We aimed to put the cost of repeatedly studying the same problems into context of the current pandemic.

Methods

Quantitative analyses were based on Canadian LTC reports and commissions identified from The Royal Society of Canada Working Group on Long-Term Care⁹, which was done using a environmental scan from 1998 to 2020, a hand search of the report citations and the identification of reports during communication with the affiliated organizations. Online resources including Google Scholar, government, professional regulatory organizations, unions, and association websites were searched using terms such as “long-term care”, “nursing home”, “residential care”, “report”, “commission”, “recommendation, and “inquiry”. The reports were sponsored by various governmental and nongovernmental organizations and authored by researchers in the field. Even though the reports are not peer-reviewed, the Royal Society working group reviewed the reports and found them to be an accurate reflection of the state of LTC⁹.

Our analysis took place from July to October 2020. Recommendations were identified from reports published in the past 10 years to increase relevance to current practice. We only counted recommendations that were specifically stated, either in a heading, in a list, or in a “recommendations” section of the report. After the first five reports were reviewed by two reviewers, a discussion was held to decide on grouping of the recommendations. The same two reviewers regularly discussed the recommendation categories through the review process. Recommendation categories were chosen to reflect meaningful differences in concept. For example, even though improving staffing was a common theme, we separated out the recommendations into (i) increasing funding for more staff, (ii) improving staff education and training, (iii) optimizing the mix of staff professions, and (iv) increasing emotional and wellness supports for staff. For the cost analysis, we excluded follow-up reports and included cost estimates in the original larger report.

An earlier version of this article can be found on medRxiv (DOI: https://doi.org/10.1101/2020.11.17.20233114).

Results

The list of Canadian LTC reports from the Royal Society commission spans the years 1998 to 2020 (n=80). There was an increase in the number of reports over time, with 10 reports in the first half of 2020 (Figure 1). Most of the reports were focused at a provincial level (n=55, 68.8%), 24 reports were based on a national level (30.0%). We found one municipal report and no reports from the territories. Ontario (n=31, 55.0%) produced the majority of the provincial reports, followed by British Columbia (n=11, 19.6%) (Table 1). More reports were funded by provincial governments (n=26) compared with the federal government (n=9). Non-profit organizations (e.g. Canadian Association for Long Term Care, Canadian Institute of Health Information) and professional unions (e.g. Canadian Federation of Nurses Unions, Canadian Union of Public Employees) or associations (e.g. Registered Nurses' Association of Ontario, Canadian Medical Association) authored the remaining 45 reports. No reports were funded by the private sector. Most of the reports focused solely on LTC (68.8%), but some reports focused on continuing care, older adults, or the health care system as well. The median report length was 40 pages (interquartile range, IQR, 21–84), with 16 reports (20.0%) over 100 pages. The median number of contributors, including authors, witnesses, and consultants, was 14 (IQR 5–26).

Figure 1. The number of Canadian reports with long-term care (LTC) recommendations over the span of 1998–2020.

Discussion

This analysis highlights the efforts of multiple organizations, both governmental and non-governmental, to address the longstanding challenges and quality issues in Canada’s LTCHs. The Royal Society Briefing Report concluded that the unresolved issues in Canada’s nursing homes have been known for decades. According to our analysis, there are numerous recommendations backed by governmental and nongovernmental groups, yet little action has followed. This inaction set the stage for increased deaths during COVID-19 pandemic and to lower quality of life in LTCHs. Our analysis further showed the substantial cost of studying the problem repeatedly over the years.

Duplicate investigation of known findings reduces value and increases waste¹⁸. From the LTC reports, issues regarding understaffing, undertraining, and the negative impact of for-profit LTC homes were repeatedly mentioned⁹. Policy change often requires persistence¹⁹, but the cost of advocating for change should be viewed from a societal context (financial and moral). Commissions and inquiries into LTC issues, like those happening or slated to begin around the country^10–12, can solidify our determination for policy change, but do not replace the need for policy implementation. Only action will help LTC residents.

Several provinces have increased wages and provided full-time employment with more appropriate compensation and benefits to stabilize the LTC workforce²⁰. The Ontario government went further to commit 4.00 hours per day of direct care for each LTC resident by 2024²¹, bringing the total care hours above the national average (3.30 hours)²². However, increasing direct care hours, while essential, is only one of the many recommendations from existing reports. Identifying the right staff mix and care team composition, providing proper education and training, and supporting staff wellness are also critical to developing a long-term workforce that has sufficient resilience to confront future crises²³. Furthermore, we should focus more attention on resident quality of life, which should be the ultimate goal of our efforts.

Although the total cost of $23 million in generating LTC reports may seem insignificant compared to a government budget, it represents a substantial, lost opportunity to continually improve Canadian LTCHs. Studying the same problems repeatedly means Canadian experts are confined to revisiting critical deficiencies in LTC instead of innovating new care models. Even if there were incremental lessons and improvements from these reports, they were inadequate in preventing one crisis after another. While Canada ranks among the best countries in the world for health innovation²⁴, this pandemic highlighted a contrasting story of neglected policy in LTC²⁵.

There are several strengths of this study. We systematically tracked down the cost of each report by contacting the sponsoring organization or consulting their global budgets. The total costs, including time donated of experts authoring these reports, were accounted for. For reports that did not have available cost data, we estimated the total cost by using reports with known costs with similar length and depth.

The main limitation of this study was the lack of true cost estimates for half of the LTC reports. Some organizations lacked transparency about costing, and others lacked detailed accounting of spending. Staff turnover and record keeping practices were barriers to accessing data, particularly for the reports produced over 10 years ago. For government agencies, we often had to call multiple departments and speak with numerous representatives and noted considerable variation in the level of disclosure. For the two military reports during COVID-19, we likely underestimated the cost since they were generated as part of military duty. The Canadian government deployed military personnel to some nursing homes due to critical shortages of staffing and resources when the pandemic started¹⁶. However, there were still considerable costs incurred by the public by having the military deployed to those LTCHs²⁶. We also grouped reports on health system improvement and care of older adults in general in this analysis because LTC is intricately tied to the health system at large. Leaders in the care of older adults, such as Denmark, design LTC policy as in integral part of their health system²⁷.

Conclusion

Over the last two decades, Canadian governments and non-government organizations have repeatedly investigated longstanding LTC issues and have largely drawn the same conclusions. Had the recurring recommendations been implemented, we would not only have improved working conditions, quality of care and quality of life, but would also have undoubtedly prevented unnecessary deaths due to COVID-19. Instead of continuing to investigate LTC issues, we should focus our resources on implementing the recommendations in the identified reports.

Data availability