COVID clock is ticking on preparing nursing homes for a second wave

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The clock is ticking on the potential for a second wave of COVID-19 at long-term care homes in Nova Scotia. The question is, despite what we know now, are we any better prepared to cope than we were last spring?

Of the 65 provincial deaths recorded in the first wave, 57 were in nursing homes and 53 of those were residents at Northwood in Halifax. The virus crept into homes with unsuspecting long-term care workers who showed no symptoms. The province currently has 20 active cases — minuscule in comparison to areas outside the Atlantic Bubble. But as the number of cases increases across the country, it may only be a matter of weeks before we experience community spread here. 

Both Premier Stephen McNeil and Dr. Robert Strang, the Chief Medical Officer of Health, have warned citizens about becoming “complacent” and encouraged us to be vigilant about wearing masks, washing hands, and not hosting house parties or large family gatherings. 

Good advice. But it’s prime time to check on what progress has been made to prevent or prepare for a potential second wave in places where the vast majority of cases erupted this spring — nursing homes.

 Where will COVID-positive residents be cared for?

Last spring, nursing homes prepared by setting aside beds in a separate-as-possible COVID unit or in an isolation area within the home. Many older homes (where “double-bunking” in a room has been the norm) are trying to keep some beds vacant. But at the same time, the Department of Health is urging homes to fill beds with new occupants or have their provincial funding withdrawn. That’s because the waiting list for long-term care beds has ballooned to well over 1500 people, hundreds of whom, as the NDP and PC parties have documented, are being cared for in hospital beds at three times the daily cost of a nursing home bed.

COVID units inside nursing homes could become unnecessary, but only if the Department of Health and Nova Scotia Health Authority proceed with their stated plan to send residents who test positive for COVID to be isolated and cared for in “regional care centres.” Aside from the plan to establish one centre in each of the four health zones, no concrete information on who will staff and operate these locations has been made available to the public or to the Nursing Homes Association of Nova Scotia. 

In response to an email asking who would operate and staff the centres, Health Department spokesperson Marla MacInnis replied, “The Regional Care Units will be staffed by the facilities where they are located. In some cases, this could be NSHA staff, as the Health Authority runs the facility. The Health Authority will provide support to the facilities it doesn’t run.”

That’s a pretty opaque response. A reading of those tea leaves suggests some regional care centres could be inside hospitals operated by the NSHA or inside nursing homes with “support” from the NSHA. It’s likely individual nursing homes are not eager to accept residents from other locations unless the Health Authority accepts responsibility for staffing and operating the “regional care centres.” Whatever the case, one week into November, this issue remains unclear.

Staff Shortages During a COVID outbreak

The September 15 report the government received from the two-person panel appointed to review what happened at Northwood stated that improving staffing will be critical to prevent a repeat of the swath cut by the virus earlier this year. During outbreaks at Magnolia Manor in Elmsdale and at Northwood (where by early April, 131 staff were off work because they were either self-isolating or afraid to return), the Nova Scotia Health Authority sent in additional nurses and infection control experts. 

According to Dr. Chris Lata, one of two doctors who conducted the Review, that help should have been summoned sooner at Northwood. 

“The directive [from the Department of Health that sent in the Emergency Response team] occurred later than would have been desired, but there were reasons for that,” said Lata during the briefing following the release of the review’s recommendations. “It wasn’t that people weren’t paying attention. They were responding to a crisis and their focus was on making sure their residents were safe in a staff loss situation.”

One of the first recommendations contained in the Northwood Review states:

Critical staff loss numbers should be a surveillance priority. A set point should be defined at which to contact the Department of Health and Wellness for staffing support.

That “set point” would be different for each nursing home, but the concept of determining a level below which staffing cannot drop during an outbreak of COVID-19 (or influenza) seems solid. The McNeil government accepted this recommendation but has so far failed to act upon it. Questions from the Halifax Examiner to the Department of Health about whether any “set points” have been determined received no response. 

By the time registered nurses from the Infirmary and caregivers loaned by other nursing homes arrived at Northwood last April — 12 days after the first positive test result — some residents were dehydrated and living in unsanitary conditions. Cleaning staff were overwhelmed trying to keep up with disinfection and disposing of a growing amount of used Personal Protective Equipment (PPE). These conditions were made public by members of the Nova Scotia Government Employees Union who had been sent in to assist. (Additional information received from staff interviewed by the Review Panel remains confidential, under the Quality Improvement and Health Information Protection Act — a mechanism chosen by the government due to a pending class action lawsuit brought by family members of Northwood residents against the nursing home and the province).

In response to recommendations contained in the Northwood Review, this year the McNeil government is adding $26 million to assist long-term care homes. The Department of Health is using some of that funding to establish four multi-disciplinary infection prevention teams — one for each health zone. Work is underway. Many nursing homes have already been visited, and unlike the confusion experienced last spring, each long-term care facility has been provided with clear instructions on where to call to report cases of COVID-19.

Some long-term care homes have begun invoicing the Health Department to pay for the hiring of more cleaning staff, as well as assistants to arrange and facilitate family visits. In the event of an outbreak, some of that $26 million can be accessed to hire more licensed nurses and caregivers to replace those off sick (provided they can be found; there’s a chronic shortage — partly because people can make better money working in hospitals). Some long-term care homes have also applied for funding to add partitions to rooms or install scanning equipment to take the temperature of staff and visitors. 

But this doesn’t address the elephant in the room: at least three reports to the McNeil government have indicated more front-line certified staff need to be hired on a permanent basis to improve care, and wages must be sufficient to fill current vacancies. That would cost much more than $26 million a year — perhaps closer to $100 million a year — to achieve. Ontario, Quebec, and BC have hired thousands more people to staff long-term care homes. But in this province, not even a pandemic has resulted in change to front-line staffing levels.

Overcrowded facilities

The Northwood Review panel recommended the number of residents (485) at the Halifax location be reduced “on a permanent basis” to prevent a recurrence of the first outbreak, during which 360 staff and residents tested positive. Although no permanent occupancy number has been chosen, Northwood has 90 fewer residents today and only 16 shared rooms, most of them occupied by couples or by choice. 

Back on September 21, Health Minister Delorey committed to eliminating 30 situations at nursing homes where residents were three to a room, or “triple-bunked.” Inquiries to the Department of Health to determine what progress has been made on that issue have been so far been unsuccessful.

Much has been said and reported about the ongoing need to create more space or build more housing to take care of elderly people who can no longer remain in their own homes. On October 15, Ottawa announced it would pay 80% of capital improvements or projects under the COVID-19 Resilience Infrastructure program. Nursing homes, schools, and health-care facilities are now eligible. Inquiries to the Department of Transportation and  Infrastructure Renewal (TIR) in the past week about when any of this $82 million will be allocated to upgrade existing long-term care homes or build new ones yielded the following response from Steve Warburton, spokesperson for the department:

Projects for the federal COVID-19 Resilience Stream are still to be determined. The new stream has expanded eligibility criteria that includes health and education infrastructure. This allows us to focus on maintenance and rehabilitation of infrastructure, and increases our ability to modify, reconfigure or build public infrastructure assets that support COVID-19 resilience measures, such as physical distancing. $82 million is eligible for this program.

As for the COVID stimulus spending announced by the province last spring, there is still no answer about whether that money will be used to create new housing for elderly people. 

“The $230 million stimulus investment announced in May is directed at fixing aging provincial infrastructure right across the province,” replied Warburton. “Any questions about investment in nursing homes should go to the Department of Health.”

So in a nutshell, no long-term care facilities appear to have been allocated funds from either the provincial or federal COVID stimulus programs. 

That doesn’t mean there won’t be. It’s early days for the federal money. It took the current government six years to get started on building new long-term care homes now underway in Cape Breton and the southwestern part of the province. 

Maybe COVID will accelerate the timeline. Or maybe it won’t. Because history shows us that provincial governments are loathe to invest in housing and caring for old people. The reason? Long-term operating costs (such as staffing) concern them more than short-term building costs covered by one-time emergency funding.

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