Ontario's long-term care wait list increased from 38,400 in April to nearly 39,000 as the second wave of COVID-19 started hitting the province, and experts say they're not surprised at the increase. Admissions to long-term care homes decreased by more than 38 per cent during the first seven months of the pandemic compared to one year prior, and the number of people declining beds also plummeted by about 85 per cent.
Observers weighed in on the data obtained by QP Briefing from the Ministry of Long-Term Care, pointing to several policy changes and the pandemic's ability to strip many Ontarians of supports they would normally have as possible explanations for the numbers.
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COVID-19 has hit long-term care homes hard and prompted the province to request the aid of the Canadian Armed Forces during the peak of the first wave in the spring. Since the start of the pandemic, 2,555 long-term care residents have died due to COVID-19, making up about 60 per cent of the pandemic-related deaths in Ontario.
The province's long-term care wait list reached 38,400 people in April as COVID-19 started to devastate nursing homes across the province. The wait list grew to 38,970 by the end of September, up from 37,000 in September 2019.
In one way, the growing wait list reflects the challenges many older Ontarians who were already struggling prior to the pandemic have faced as a result of it, said Dr. Samir Sinha, director of geriatrics at Mount Sinai and the University Health Network.
"I’ve been seeing many more patients coming into the hospital who sadly just became neglected in the community, they no longer had access to those kind of informal supports from family members, friends, or even some of those basic community programs that they relied upon to remain healthy and independent," he said. He pointed to day programs for people with dementia, for example, that were shuttered when the pandemic hit, becoming "the straw that broke the camel’s back" for some.
"I can tell you many stories about patients who were found basically by the landlord, buried under their bed covered in feces, that was one of the patients I remember admitting back in the summer because everything fell apart," he said.
Tamara Daly, a professor with York University's School of Health Policy and Management and director of the university's Centre for Aging Research and Education, agreed, adding that the need for long-term care is independent of what is happening with COVID-19.
"People need long-term care because they need long-term care," she said. "Whether or not that environment is actually the best that it can be is separate from the need for it, so I think that's why we see a rise in the wait list and why we see a decline in the people who are saying 'no' is because needs have probably gone up quite a bit."
People's social networks and support systems have become more strained and care responsibilities have also increased, she said. "Community centres and day programs and home care have also reduced their capacity to provide services and to support people in their home environments and so it's kind of a perfect storm."
Meanwhile, as hospitals filled up after the first wave and a second wave was being anticipated, hospitals got access to "crisis placing people," explained Sinha. Previously, placing individuals on the "crisis" list, thereby prioritizing their admission to long-term care, was typically done from the community, encouraging hospitals to put in place supports that could allow an individual to return home and sometimes prevent them from having to go into long-term care.
"Now that ... they're able to crisis place people directly from the hospital, it’s actually made applying to long-term care the easiest thing to do for them," said Sinha, given that it can be "twice as hard" to get someone back into the community with adequate support. "It’s a perverse incentive that’s probably driving more people onto the wait list, number one, and more people from hospital going into long-term care homes."
He noted that while long-term care placements from hospitals made up 19.2 per cent of the total placements from July to September in 2019, and placements from the community accounted for 68.9 per cent, according to ministry data, that changed in 2020. Placements from hospitals made up the largest share at 56.7 per cent during the three-month period this year, while placements from the community were down to 35.9 per cent.
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Overall, admissions fell during the pandemic compared to last year. While there were 13,165 people placed into a long-term care bed from March to September 2019, there were just 1,363 during that period in 2020 — a 38.7 per cent decline. These numbers only include placements from hospitals and the community and not transfers between homes.
Admissions were affected in the spring as long-term care homes were battling the spread of COVID-19 through their facilities, with the government issuing a memo asking hospitals to stop transferring patients to long-term care and retirement homes. While readmissions were allowed to resume by the end of April if a home was not in outbreak, initial admissions from a hospital to a long-term care home continued to be paused for a while longer.
Dr. Nathan Stall, a geriatrician with the Sinai Health System and University Health Network, said he's "unsurprised" by the wait list increase, pointing to a policy change made in June as one of the reasons.
Chief Medical Officer of Health Dr. David Williams <a href="http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/directives/LTCH_HPPA.pdf" target="_blank" rel="noopener noreferrer">updated</a> a directive on June 10 to say that individuals going into long-term care would need to be placed in a room "with no more than one other resident." This meant people could no longer be admitted into a room with three or four beds — a common feature in some of Ontario's oldest homes that has been cited as one of the reasons for rapid spread of COVID-19 in nursing homes.
"So this is an understandable consequence of that," said Stall, of the wait list. "The question is … are they providing the increasing number of people that are waiting in the community for long-term care with the necessary home and community care supports that they need because their wait is now going to be longer?"
The government announced $20 million during the past two months for "Community Paramedicine for Long-Term Care" programs in various Ontario communities. It said $5 million would be allocated for the first phase in Brant County, Ottawa, Renfrew County, York Region and through the Cochrane District Social Services Administration Board to try to help seniors on long-term care wait lists stay at home longer. In November, the government invited other communities to apply to provide the program.
Stall said this program could help along with increases to the number of hours of home-care services and supports that older Ontarians receive.
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During the first seven months of the pandemic from March to September, 267 people declined a long-term care bed — what the government refers to as "long-stay bed offer refusals." This number includes those living in the community, individuals in hospital and people refusing to be transferred from one long-term care home to another, with nearly 60 per cent of the refusals in 2020 coming from the community. During that same period in 2019, there were 1,867 declines, meaning the number of people declining a bed in 2019 versus 2020 dropped by 85.7 per cent. Just counting declines from hospitals and the community, the percentage drop is the same from 1,438 declines in 2019 and 207 in 2020.
Both Sinha and Stall noted the marked decrease in the ministry's data on people declining beds during the pandemic. Either most people are taking a bed when they are offered it, or the data isn't capturing individuals who decline a bed, but are now able to remain on the wait list as per a policy change, they speculated.
The province made changes to admissions and readmission requirements in March, with one being that individuals who decline a bed during COVID-19 "are not removed from the waiting list nor moved down." Previously, if someone declined a spot, they would be removed from all waiting lists and then have to reapply <a href="https://www.ontario.ca/page/about-long-term-care" target="_blank" rel="noopener noreferrer">after 12 weeks.</a>
"As a geriatrician I do know many folks who've taken advantage of that opportunity to do that," said Sinha, adding that the pandemic has seen many people pull their loved ones out of long-term care or delay their admissions.
Asked who is included in the data on long-stay bed offer refusals and whether the numbers reflect individuals who declined a spot and stayed on the wait list, people who declined and wanted to be removed from the list, or both, the ministry said the database it extracted the numbers from "does not provide details regarding the refusal. The information only identifies that a bed offer was refused."
Meanwhile, Daly noted that with fewer people being placed into long-term care and fewer people also seemingly refusing spots, "it leads me to ask the question, is this as a result of there being fewer offers?"
As for transfers between homes, Sinha said the data indicate they're still happening — 317 from July to September compared to 714 during that time in 2019 — with the refusal rate being lower in 2020 compared to 2019 (there were 165 refusals during the three-month period in 2019 and six this year).
"That's probably because people are no longer refusing the opportunity to get out of the home that they want to get out of; they might have more of an incentive to get out of the home that they're in," he said.
And while the data doesn't capture the second wave, Stall said he expects "a lengthening of the wait list and probably stable to lower levels of occupancy."
"November was not a particularly enticing month for people to enter long-term care," said Stall. According to provincial data, more than 260 long-term care residents died in that one month alone.
With deaths going up and the pandemic challenging the province's health-care system, Stall said "there's the real potential for catastrophe to happen again."
Similar to the first wave, families likely don't see this as "the most enticing time" to enter long-term care, he said.
"Many would probably prefer to wait until the post-vaccine era," Stall added. "If the sector runs into real crises, will they increase efforts to de-crowd nursing homes, which I think are necessary, will they further restrict admissions?"
Meanwhile, long-term care occupancy numbers for September 2020 showed that at the time there were 6,508 vacant beds, with the ministry adding the caveat that the numbers reflect just one point in time and are subject to change.
Sinha argued that if the pandemic ended and those beds were filled, the wait list would be down to nearly 32,500 people.
"What this clearly demonstrates is that thousands of people have likely pulled themselves off the LTC wait lists by withdrawing their names off wait lists (before they could refuse a bed) while others have simply decided that LTC is no longer a preferred option for themselves at a staggering rate during the pandemic," he said.

‘It’s kind of a perfect storm’: Experts weigh in after LTC wait list increased to 38,970 this fall

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