New research has found that residents of Ontario's more crowded long-term care homes — where more residents live in four-bed ward rooms — were twice as likely to contract COVID-19 and die than those in less crowded homes.
The findings shed light on the tragedies that have occurred as the province seeks to overhaul its long-term care system and they inform the debate over the role of for-profit companies. Not only did the researchers find that for-profit homes are more likely to have four-bed ward rooms, they found that this tendency explains why for-profit homes have experienced higher rates of infections and deaths than non-profit and municipal homes in the COVID-19 pandemic.
The two studies are by teams of researchers affiliated with Public Health Ontario, the University of Toronto and some of the province's major hospitals. They examined data on Ontario's more than 600 long-term care homes and more than 78,000 residents, 6.6 per cent of whom developed COVID-19 infection and 1.8 per cent of whom died before May 20.
They found that the more-crowded homes were just as likely as the less-crowded homes to have COVID-19 introduced inside. That was largely dependent on the concentration of cases in area around the home and it's believed nursing home staff were largely responsible for bringing the virus into the homes, said Dr. Nathan Stall, an author of both studies.
"But once it gets introduced, we know that nursing homes can be like tinderboxes, particularly these homes that are more crowded," he said in an interview with QP Briefing. "These are the ones that have the larger and deadlier outbreaks — the more crowded the home was, the larger that outbreak was and, in the end, the more deaths we saw overall."
The findings align with reporting by QP Briefing in April that found the province's most severe outbreaks at that point had occurred in older homes with multi-bed ward rooms that don't meet the province's current design standards.
The researchers came to their conclusions concerning ward rooms by ranking each LTC home on how crowded it was at the outset of the pandemic on a scale of one to four, based on the average number of residents living in each room, with four being a fully occupied home consisting entirely of four-bed wards.
That index is largely dependent on the provincial design standards the homes meet. The province prohibited ward rooms with more than two beds when it updated the standards in the late 1990s. However, a little over a third of the long-term care homes in Ontario still do not exceed the previous standard, set in 1972, and still have four-bed ward rooms.
The researchers also found that if, prior to the pandemic, the province had converted all of the four-bed wards into two-bed wards, 988 infections of COVID-19 and 271 deaths would have been prevented.
Stall said that's a particularly important finding, as the province has asked the owners of the old homes to update them to modern design standards, but they have so far refused. The homes with the old design standards are predominantly owned by large chains, he said.
The first of the pair of studies found evidence that for-profit nursing homes had larger COVID-19 outbreaks and more COVID-19 resident deaths — another finding that echoes news reports. However, the researchers were also able to determine that differences between outcomes in for-profit and non-profit homes was mediated — or largely explained — by the different design standards, which was examined in the follow-up study.
The studies did not examine staffing levels in the homes, another issue that has often been cited as a concern. Stall said data on how many staff are working in long-term care homes on each shift is not available. However, he noted that previous research has indicated for-profit homes tend to have lower staffing levels as well.
Stall said the studies' findings show the debate on the role of profit in long-term care is "more nuanced" than saying "for profit is bad, let's get them out" because some for-profit homes have done well in the pandemic.
"I think there are understandable reasons why people bristle at the fact of having for-profit entities within the long-term-care sector," he said. "In many ways, they face this sort of impossible choice of being accountable to their owners and shareholders and also being accountable to the residences. What do they do with the profits that they make at the end of the year? And who are they most accountable to? And so, and is that reflected in the fact that these homes have chosen not to upgrade their facilities? That's an obvious question to be asked here."
The province launched a capital renewal program a decade ago, but it didn't see the expected uptake. It was relaunched in 2014, with the goal of bringing all homes up to modern standards by 2025. In an April interview, Ontario Long-Term Care Association CEO Donna Duncan told QP Briefing the province's program for capital upgrades remains "unworkable" and underfunded, and her organization has been calling for changes that would see homes built and staffed according to the needs of the residents. Her organization is calling for the province to plan for a second wave of the pandemic, including supporting older homes to enable effective infection prevention and control and expediting the capital redevelopment program.
The studies are in the pre-print stage, which means they are yet to be peer-reviewed. But Stall said the findings have already been shared with the province. On June 10, the province's Chief Medical Officer of Health issued a directive banning residents from being admitted into rooms with more than one resident already living in them, effectively banning three- and four-bed ward rooms going forward. However, residents who already live in those ward rooms are not affected.
Stall said he supports that decision, but it has consequences.
"There are thousands of people, many of whom are in crisis, that are waiting in the community to get into long-term care," he said. "And so you're going to have to make investments in home care, beyond the limited amount that people can get while they're waiting for long-term care. And you may have to get creative about using other spaces for people who are in crisis who need nursing homes without putting them into crowded spaces."
On Thursday, Premier Doug Ford said there should be a maximum of two residents per room. "Once it gets into these homes — I'll tell you through what I've seen — it's tough to get your hands around it. But there's four to a room in some cases. So maximum there should be ever is two to a room," he said.
In a statement, Long-Term Care Minister Merrilee Fullerton's office said she has publicly recognized the fact that "ward rooms and congestion have amplified the person-to-person and asymptomatic spread of COVID-19 in our long-term care homes, badly exacerbating this crisis."
"These are long-standing structural and capacity issues that, coupled with a severe staffing shortage that predates the virus, have led to the tragedy we have seen in our homes. We have known for decades, as our population has aged, that these issues were mounting, but they went unaddressed by the previous government," the statement said.
"Long-term care is a huge priority for our government and every option is on the table to make it better," it continued. "We are forging ahead with the critical work we had underway before this pandemic hit, and will leave no stone unturned as we undertake badly needed system transformation. We owe it to the families of those in long-term care homes to provide a safe environment for their loved ones today and into the future."
NDP Long-Term Care Critic Teresa Armstrong said the fact that more for-profit homes have not upgraded their facilities if part of a pattern of cost-cutting and "speaks to that they're worried more about the profit than about the care."
"We can't forget, when we're talking about for-profit homes and the people in them, that they have families and my heart goes out to the families who loves loved ones during COVID-19," she said. "It's one of the worst ways, most tragic ways to lose a loved one."