Dear Colleagues,
Coronavirus disease 2019 (COVID-19) has not been “the great equalizer” as some have intimated: it has exposed gaps in care for vulnerable populations, such as the homeless, those with addictions, those in prisons, and those in long-term care (LTC) homes. More than 80% of COVID-19–related deaths in Canada have occurred among LTC residents.1 Here are a few of my observations:
Support, care, and basic needs matter.
Long-term care residences are not hospitals for transient stays; they are homes for the residents, and some of them know that these homes are where they will end their days. Basic needs must be met.1–3
Safety and working conditions in LTC homes need attention.
“The rates of injury and illness absence are highest in long-term care of any place in Canada.”2 As of late April 2020, in Ontario, 1089 of the 1368 health care workers with COVID-19 work in LTC.4 Given the frailty and physical and cognitive impairments of the residents, they require skilled care by personal support workers and cleaning and food services staff, in addition to nurses. Adequate remuneration and workplace safety are paramount; workers must have “time to care.”
Social supports are needed, even during a pandemic.
We all know the effects of relative isolation; prolonged restrictions have had a profound effect on LTC residents and their caregivers. As we learn from this terrible experience, let us hope that we find the right balance to address this.
Is it time to include LTC in universal health care?
Just under half of Canada’s LTC homes are private and for-profit.2 More than 50% of LTC homes in Ontario and BC are privately funded.5 The federal government provides funding to provinces and territories for health care, largely with no strings attached.5 Provinces and territories fund and regulate public LTC homes and are under increasing financial pressure. Recently, gaps in funding and inconsistencies in the application of standards of care were uncovered. Do we really need more inquiries, or do we need a collective will and action plan to address this and support a high quality of life in the elderly?
Family doctors have provided coverage in LTC for many years. Of the 4000 CFPC members who responded to our most recent COVID-19 survey, 15% included LTC or personal care homes in their practice settings. This figure includes some of the 22% of family physicians who started to work in new settings owing to the pandemic.6 In the midst of the worst of the pandemic, collaborative initiatives emerged between LTC homes and acute care hospitals7; mobile teams were created to work with family doctors, nurses, and other front-line staff in LTC homes in collaboration with local public health to assist with COVID-19 testing and infection prevention, and to control education, staff shortages, and personal protective equipment supply, removing administrative roadblocks. When team-based care is deliberate, great things can happen.
In our follow-up work to the Family Medicine Professional Profile, through a participatory approach, we defined the core professional activities of family doctors. This work is informing the Family Medicine Residency Training Profile.8 Our draft describes family doctors’ core professional activities in the care of older adults as the “provision of primary care for patients with unique, complex medical needs in the home, long-term care facility, and other community-based setting.”8 Related activities to guide residency training are described: advance care planning and decision making regarding goals of care; communication with patients and caregivers, including family meetings and virtual care; availability, in person and virtually, to support patients, family, and other care providers; completion of medical documentation and forms in accordance with local regulations; and ensuring personal safety when providing care outside the clinical setting.
The CFPC created a Certificate of Added Competence (CAC) in care of the elderly (COE). The Family Medicine Residency Training Profile describes holders of the COE CAC as “increas[ing] the capacity for provision of care to the aging adult through direct patient care, consultations, peer support and education …. They augment and support the care provided by family physicians, other physicians and other care providers typically around issues of frailty, complexity, comorbidity and functional decline in the elderly.”8 Currently, 373 family physicians have a CAC in COE.
Dr Victor Do, a recent medical graduate from the University of Alberta, summed up our role as educators with the words of his mentor, Dr Lyn Sonnenberg: “When you transform the learner, you transform care.” The CFPC and our 17 family medicine residency programs are committed to supporting our learners and family doctors to meaningfully contribute to care of LTC residents, and to a “life worth living.” Kudos to all physicians and front-line workers providing care and support to older Canadians during these extraordinary times.
Footnotes
Cet article se trouve aussi en français à la page 539.
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References
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