COVID-19 and the challenges in homecare

Homecare, like all other health services, faces serious challenges continuing to provide services through the pandemic. Government guidance for this sector provides instructions for screening as well as use of PPE for clients suspected or confirmed COVID+. For these clients, “care providers should be delaying care if possible and only providing essential medical services.” This has also meant implementing new home care delivery models to support homecare clients and patients, increasing the delivery of virtual care by nurses, physiotherapist, social workers and other home caregivers. The government says its intention is to bring more homecare services online “in the weeks ahead.” The government has also issued guidelines that has nurses, personal support workers (PSWs) and other home care providers screening themselves for symptoms of the virus every morning.

PSWs who care for clients inside their homes are among the essential service providers who don't feel safe on the job due to a lack of PPE amid the pandemic. "It's very, very scary," said Lindsay Couture, the executive director for Ajax/Pickering with the Ontario Personal Support Worker Association. "We just keep going forward, follow precautions and just hope we don't get [COVID-19]." Couture runs her own PSW business, Oakwood Home Healthcare, and says it's been "impossible" for private companies like hers to find PPE. She managed to get some mask donations earlier, but has had a hard time finding more. That's left her and other PSWs in Durham with no choice but to enter homes of clients, many who are elderly or immuno-compromised, unprotected to help them with physical tasks like bathing, dressing, and toileting.

Clients are also tense. As someone who has PSWs enter her condo for several hours a day, six days a week, Mona Kornberg is also taking precautions. Her husband Jacques Kornberg was diagnosed with terminal cancer six months ago. He now requires help for any physical movement. She ensures anyone who enters her home washes their hands properly and regularly and uses the disinfectant wipes often. Mona says it's "been a struggle" having a rotation of PSWs, whose services are funded by the Ontario government, coming into her home. She screens them each time about their social distancing and whereabouts, and those of their other clients. She says she's fought hard to narrow down the roster of PSWs who enter her home each week, but is planning to move onto a private agency in hope of finding more consistent care. "People who are vulnerable like my husband need the consistency to feel safe."

Shirlee Sharkey, president and CEO of SE Health, says the government has to consider new care models that ensure we’re not spreading the virus from home to home. Currently, the home-care model sees nurses or PSWs visit an average of six different homes a day, and could include a nursing home, Sharkey said. That should change to having the same nurse or PSW exclusively visit the same client. If a client needs three PSW visits a day, why not have one worker put in five or six hours a day dedicated to that one client? Sharkey, whose 8,000 employees in Ontario make 20,000 home-care visits each day, said fear of infection is one reason her non-profit agency has seen a drop in home care services by up to 30 per cent. Patients and families were nervous and cancelling visits, at least short term, and the staff are nervous, both with the shortage of PPE and nervous with the community spread of COVID-19. This trend needs to be reversed, she argued, because the more people turn away from home care the more likely their illnesses will force them into already strained hospitals.

Many home care agencies propose temporarily transforming the way home care currently operates into a COVID-19 pandemic response strategy that supports one patient per caregiver staff working on a full-time basis. The current home care model works on ensuring that service planning assessments are completed by case managers, and then optimizing schedules to reduce the total cost of services delivered to the highest number of people. The proposed new temporary model would be about increasing self-isolation of patients by drastically reducing the number of encounters a caregiver has with multiple patients, with the goal to assign one patient per caregiver. Implementing this temporary model requires a ministerial order. RNAO believes such a new model is best for COVID-19 as it improves self isolation for clients and it reduces the chances of spread. It also optimizes continuity of care and caregiver leading to better outcomes.

One of the problems Sharkey mentions is the lack of PPE, a concern that sounds all too familiar for our readers. The amount of equipment that once lasted a full year is now being used up in a month, Sharkey said. It keeps her constantly competing to buy the little equipment available, which increasingly is being reserved for staff in hospitals and nursing homes. A model with one care provider working exclusively with one home-based client would significantly reduce the need for masks. That model would require a fundamental redesign of the provincial approach, which currently sees home care as a piecemeal service divided into specific tasks that get performed by the hour. “Home care has been an afterthought for years and during this pandemic we in the community are saying, ‘Listen, this has to part of the whole central planning,” said Sharkey, arguing that the government’s vision of health care has traditionally been focused on hospitals. “Everyone is being told to stay at home,” she added. “So we want to make sure that we can provide an environment in the health care system where people can stay at home.”

Others share the concerns. If home is the safest place for all seniors to be these days, shouldn’t Ontario do more to keep them out of long-term-care facilities and enable them to live at home again?, asks Steve Paikin. And shouldn’t the province be doing everything it can to improve homecare so that residents who can go home or live with family members are able to do so? He points out there has been no specific relief funding or targeted investment in homecare during this pandemic. “In fact, in Ontario, we’re actually reducing the availability of homecare services,” said a leading provider. Furthermore, hospitals are discharging older patients into long-term-care homes or hotels, where they’re less safe, rather than to their own or their family’s homes, where, with some beefed-up care, they’d be in far less danger.

Your messages: Voices and responses

Every day we welcome new readers to this daily report: thank you deeply for the work you do during this public health crisis, and also for keeping us well informed. You can see previous reports at RNAO updates and resources on COVID-19 for members and other health professionals. Feel free to share these updates with other health professionals and other organizations both at home and abroad. RNAO media hits and releases on the pandemic can be found here. Daily Situational Reports from Ontario's MOH EOC can be found here. Many of the articles you see here are posted in my blog, where you can catch up with earlier issues.

Thank you for your messages! Today I focus on two issues:

Need for accommodation away from home. We have been contacted by a number of health care providers asking about temporary accommodation for those working on the front lines. In our research to enlist hotels that will provide free or discounted accommodation we became aware of a program available to hospital staff that need temporary accommodation. The Ontario government has issued guidelines to hospitals for temporary accommodation for patients and for staff (see here). If you need temporary accommodation close to your hospital or for self-isolation we encourage you to contact your manager or human resources department to inquire. You should not be out of pocket to access this program.

Don’t spread COVID-19. With permission, I share this message from Barbara Loomis as we must heighten awareness: “I keep hearing of the lack of PPE in LTC. No amount of PPE will replace good old common sense. Apparently we now have a restriction on staff only working for one facility (a restriction way too long in coming), but I have not heard of a restriction that forces those workers to change their clothing when leaving a facility – including changing shoes from outside shoes to shoes only worn in the facility. Common sense should tell you that uniforms/scrubs worn in the facility should not leave the facility except in a closed bag to be taken home and washed. This washed clothing should be taken back to the facility in a closed bag and put on when you arrive for your shift. This applies to shoes also. I almost had heart failure when a health worker was interviewed leaving the place of employment wearing the same clothing worn for the past eight hours in a facility that had a COVID outbreak. What is to stop that employee from stopping to pick up a loaf of bread on the way home and thus contaminating all those around? I know this is a widespread practice across all sectors, and it must be stopped.”   

You can read earlier responses here.   

MOH EOC Situational Report #80 here for Tuesday, April 14

 Situation:

• 483 new cases were reported today in Ontario, bringing the cumulative total to 7,953 (this includes 3,568 resolved cases and 334 deaths).
• In Ontario, a total of 113,082 people have been tested, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 2,107 tests under investigation.
• 769 patients are currently hospitalized with COVID-19; 255 are in ICU; and 199 are in ICU on a ventilator.

EOC report #80 for April 14 informs of the following actions taken: 

• The Government of Ontario announced it is extending the Declaration of Emergency under the Emergency Management and Civil Protection Act for a further 28 days, until May 12. 

RNAO’s ViaNurse Program

RNAO launched its COVID-19 ViaNurse program on March 13 and it has already registered 274 nurse practitioners (NPs), 1,000 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 7,155 RNs for virtual/clinical care.

RNAO is actively staffing nursing homes and retirement homes requiring NPs, RN and PSWs; so far, 400 organizations have registered. We have also staffed many hospitals and indigenous communities. We urge CNEs, CNOs, and managers – in all sectors and regions of Ontario - to access this talent now to build HR surge capacity. For details and forms, please go here.

Staying in touch          

Please continue to keep in touch and share questions and/or challenges of any kind, and especially shortages of PPE. Send these to me at dgrinspun@rnao.ca. We are responding daily and are continuously solving your challenges. RNAO’s Board of Directors and our entire staff want you to know: WE ARE HERE FOR YOU!

Thank you deeply colleagues in the front lines; in administrative roles; in all labour, professionals and sector associations, and in governments in Ontario, in Canada and in other regions – especially New York and the rest of the United States, Italy, Spain, France, Iran and Germany – now hit the hardest. We are here with you in solidarity. These are stressful and exhausting times; the only silver lining is coming together and working as one people – for the good of all!

Together, we are and will continue to tackle COVID-19 with the best tools at hand: accurate information, calmness, determination and swift actions. 

There has never been a better time to join RNAO. We don't need to tell you more about RNAO's leadership and influence in policy, practice and media. Show your support for RNAO by joining today. There is a special offer. It is only $100 (instead of $265) with PLP included. If you are on mat leave or work 15 hours or less per week on average, it's only $87.83 with PLP included.

Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO  

RECENT RNAO POLICY CORNER ITEMS:

14 April - Reprocessing Of N95 – An Update – go here.

14 April - A New COVID-19 Facility For Persons Experiencing Homelessness In Toronto – go here.  

13 April - Practical Tips for Safe Use of Masks – go here.

10 April - Ontario’s Tragedy in Long Term Care Homes and Retirement Homes – go here.

10 April - RNAO Action – Supporting Long-Term Care – go here.

10 April - Update For Nursing Students – NCLEX Exam – go here.

9 April - Celebrating Passover, Good Friday, Holy Saturday, Easter Sunday and the start of Ramadan during a pandemic – go here.

9 April - Guidance on use of N95 mask – go here.

7 April - Sentinel surveillance and on-site testing in the homeless service sector – go here.

7 April - Reprocessing of n95 – safe? – go here.

5 April - We must change the way we do testing and case definition – go here.

5 April - Ringing the alarm bells on critical care beds – go here.

4 April - COVID-19, stay at home and domestic violence – go here.

We have posted earlier ones in my blog here. Please go and take a look.

Information Resources

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers. 

Ontario’s health provider website is updated regularly with useful resources here.

Ontario’s public website on the COVID-19 is there to inform the general public – encourage your family and friends to access this public website. The WHO has provided an excellent link for you to share with members of the public here.

Please promote the use of Ontario’s COVID-19 self-assessment tool: It also has a guide where to seek care, if necessary. Its use will provide the province with real-time data on the number and geography of users who are told to seek care, self-isolate or to monitor for symptoms. Data will inform Ontario's ongoing response to keep individuals and families safe.

Health Canada's website provides the best information capturing all of Canada. It contains an outbreak update, Canada's response to the virus, travel advice, symptoms and treatment, and resources for health professionals.

The World Health Organization plays a central role in addressing the COVID-19 pandemic. See here and here.

You can find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.

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