COVID-19, Long-Term Care and Retirement Homes

COVID-19, Long-Term Care and Retirement Homes: the Kingston, Frontenac, and Lennox & Addington (KFL&A) experience Kieran Moore, MD, CCFP(EM), FCFP, MPH, DTM&H, FRCPC Medical Officer of Health, CEO KFL&A Public Health th October 8 , 2020 Professor of Emergency Medicine, Queen’s University Program Director, Public Health A presentation prepared for the Commissioners of and Preventive Medicine, Ontario’s Long-Term Care COVID-19 Commission Queen’s University

Healthy People, Healthy Places Overview

• KFL&A region • COVID-19 in KFL&A LTC/RH • KFL&A pandemic approach • Recommendations for consideration

Kingston, Frontenac, Lennox, and Addington Health Unit

KFL&A: 27 Senior Homes

11 long-term care homes (LTC) 16 retirement homes (RH) 2600 LTC/RH residents Ontario Orders, Directives, Memorandums for Long Term Care homes

12 March 30 March Ministry LTC Memo 13 March CMOH Update Directive #3 • Begin active screening of all staff, CMOH Memo • Active screening all staff, essential visitors, residents, new and returning visitors, residents twice daily admissions • Only allow essential visitors • Staff and resident cohorting • Follow Ministry of Health guidance for respiratory outbreak

CMOH Directive #3 CMOH Directive 1 No short-stay absences Limit number of staff • Use appropriate PPE for all HCWs working in multiple locations 12 March 22 March Ontario Health Recommendations COVID-19 in Senior Homes Residents & Staff

1 Case 0 0 COVID-19 in Staff Hospitalizations Deaths Antibiotic Stewardship

Since 2012: Program to encourage judicious use of antibiotics in LTC • Education • Resources Ontario Public Health Standards 2018

• Prevention • Detection • Management • respiratory infection • gastroenteritis

2018 Outbreak Protocol available here Pro-active preparation

• Pre-existing strong relationships between Public Health and senior homes • Communication, collaboration, cooperation Proactive preparation

Annual updates with LTC/RHs: • Influenza • Outbreaks • Education

"Flu shot" by National Institutes of Health (NIH) is licensed under CC BY-NC 2.0 Proactive preparation

IPAC Nurse dedicated to working with LTC/RHs throughout influenza season for many years Proactive preparation September 2019 Influenza Preparedness Workshop and Report (released August 16th, 2019)

Hosted by: KFL&A Public Health, Hastings Prince Edward Public Health, and Leeds, Grenville and Lanark District Health Unit Proactive preparation 2019

Table Top gaming exercise for influenza outbreak

Homes and providers stepped through an outbreak scenario and discussed possible responses KFL&A Public Health Regular Communication

• Support and consultation Long-term Care and Retirement Home • Advice on outbreak management and Nurses infection prevention and control (IPAC) Medical Directors Administrators • Link with acute care for clinical support What made KFL&A PH respond early to SARS-CoV-2?

5 Jan 2020 WHO reports cluster of cases of pneumonia of unknown cause in Wuhan China and advised Member States to take precautions to reduce the risk of acute respiratory infections

January and February 2020 • Nursing Home outbreak in Washington State in the USA (travel)

• epidemiological insights point to most vulnerable

https://ig.ft.com/coronavirus-lockdowns/ During the Pandemic

March 5th Educational Session for regional primary care leaders: • Science • Epidemiology • Symptoms • Testing During the Pandemic

Weekly teleconferences with senior homes and medical directors

Twice weekly teleconferences with nurse leads and administrators

Weekly coordination meeting with acute care sector and hospital IMS During the Pandemic March 10th, 2020 Augmented inspections in senior homes Inspector + nurse teams inspect all senior homes for IPAC adherence

• 4 rounds of inspections

• IPAC checklist for each round with additional requirements as COVID-19 progressed

• Supervised by IPAC lead Inspections of LTC and RH

Pandemic declared Started early!! March 11th, 2020 March 10-13

Round 1: Visited ALL homes

31 repeat visits to 19 homes (assessed as not well prepared) KFL&A PH pandemic response actions for Early Lockdown March 17th LTC and RH • Restriction of visitors Pandemic declared • Non-essential appointments March 11th, 2020 canceled • Active screening of staff and any visitors Round 1 inspections March 10-13

Inspection checklists components

Main entrance/visitors Care area/residents Testing • Signs posted • New residents screened • Symptomatic • ABHR at reception • Residents monitored daily people tested • Symptomatic residents isolated • Essential visitors only • At least 4 • ABHR/PPE available at point-of- testing kits • Visitors screened care available

Admin Staff • Substitute decision-makers • Knows how to use PPE identified • Knows when to isolate (symptoms, • Clear medical directives travel, contact) • Environment reconfigure to • Signs are posted in staff areas (eg, promote social distancing break room) • Staff can list at least 2 resources for reliable information about COVID-19 Inspections: progressive enforcements

Public health Warnings and orders for homes specific timeline with continuous Fines to rectify issues (Health Protection and Promotion Act Section 13) Inspections: progressive enforcements

two tickets have been issued to LTC/RH under the Re- opening Ontario Act

Public health Warnings and orders for homes specific timeline with continuous Fines to rectify issues (Health Protection and Promotion Act Section 13)

five section 13 orders issued During the Pandemic August 10th: Worked with post-secondary schools: • strategy to support student clinical placements in LTC/RH (conditions and criteria)

At St. Lawrence College: At Queen’s University: ~350 registered nurse ~50 undergraduate students students ~ 150 practical nurse ~ 35 Nurse Practitioner students students

4-10-week placement in All students 2 days/week clinical settings in clinical setting; fourth year 5 days/week During the Pandemic

Initiated Assessment Centre model in the province • Followed global and national epidemiological progression • Aggressive testing strategy Universal testing

• May 4-15 in LTC homes • Provincially mandated • Tested all asymptomatic residents and staff • Aggressive testing strategy with other viral pathogens as a quality assurance marker • No cases Community initiatives

Community control of COVID has contributed to low rates in senior homes: • Early expanded testing – No travel requirement – Atypical symptoms • Businesses closures • Guidelines around social distancing • Community compliance During the Pandemic August 2020: Conducted Tabletop Exercises with LTC/RH • COVID-19 outbreak management • Influenza outbreak by opensourceway is licensed under CC BY-SA 2.0 management • Scenario with reduced staff capacity (illness) New program: LTC+: acting on pandemic learning together

6 key areas: • preparation • prevention • people in the workforce • pandemic response and surge capacity • planning for COVID-19 and non-COVID-19 care • presence of family Mobilizing the local Community of Practice in East Region for Retirement Homes and other Congregate Settings 1. In the East Region, local and OHT partners will be brought together to ensure consistency in assessment, support, and implementation of regional and provincial guidance and best practice in retirement homes and other congregate settings 2. Clinical IPAC Leads will also utilize the Clinical IPAC Coordinator and IPAC Extender Team resources to serve their congregate care spoke partners, facilitate the local CoP, and communicate up and down to the regional coordination table to flag concerns 3. Escalate matters related to testing, human health resources, PPE and others to Toronto Region Operations Lead

Primary Care Other congregate Spoke partner Regional Table setting spokes (Community reaches into Health Centres, Co-Lead hub for etc.) support Clinical Clinical IPAC Extender Retirement Team (RN/OT) Home IPAC Lead IPAC spokes Coordinat

Long Term Care or IPAC Extender Home spokes Team (RN/OT) IPAC Extender Relevant Public Team (RN/OT)

Local / Sub-regional Health Community of Practice (in outbreak) Plan for COVID-19 and Influenza • Protocols for testing for COVID-19 and influenza

• Plans to prevent coinfection of COVID-19 and influenza

• Cohorting residents based on symptoms and/or pathogen

• Have areas that can be used as designated cohort units

• Have staffing capacity to cohort staff to separate units Key recommendations for Local Public Health working with LTC/RH

1. Be proactive and operational 2. Develop relationships with all institutional and community players (hospitals, homes, primary care, community care) before the crisis 3. Conduct regular and unannounced inspections to ensure that plans are being implemented properly 4. Communicate, collaborate, cooperate Revised Outbreak Management Guidance resource available here

PHO resource available here Questions? Extra Slides for reference Number of COVID-19 Affected Long-Term Care Homes across Jurisdictions in Canada (shown as a percentage of total)

Canada 5801 1125 Quebec 2215 568 Ontario 1396 436 New Brunswick 468 2 Saskatchewan 402 3 British Columbia 392 39 Alberta 350 58 Manitoba 261 5 Nova Scotia 134 13 Newfoundland & Labrador 125 1 Prince Edward Island 39 0 Northwest Territories 9 0 Yukon 5 0 Nunavut 00

Source: REIMAGINING CARE FOR OLDER ADULTS page 7 Total Homes Total Affected Comparison of Characteristics of LTCs Ontario British Columbia Residents appear more medically and functionally complex (could Residents appear less medically or functionally complex be different finding formulas) $203 funding per resident per diem $222 Staff underpaid, few FTE, multiple PT roles across LTC settings, Same subcontracted staff (laundry, cooking) More likely to have shared rooms Less likely to have shared rooms 58% LTC managed on a for-profit basis 34% LTC managed on a for profit basis Mandated annual inspections up to 2018, then transitioned to risk- Mandated annual inspections of all LTCs based framework (e.g., in 2019 only 9 of 626 LTC homes in Ontario had comprehensive inspection)

Source: Covid-19 in long-term care homes in Ontario and British Columbia Michael Liu, Colleen J. Maxwell, Pat Armstrong, Michael Schwandt, Andrea Moser, Margaret J. McGregor, Susan E. Bronskill and Irfan A. Dhalla CMAJ September 30, 2020 cmaj.201860; DOI: https://doi.org/10.1503/cmaj.201860 Comparison of Characteristics of LTCs Ontario British Columbia Links between health system partners not as strong Stronger links between hospitals, LTC and public health

Health system in state of flux Health system stable

Communication from CMOH and elected officials less coordinated Communication more coordinated

Single site LTC work policy April 14th Single site LTC work policy March 26th

Military requested to assist high-risk homes in April and May Measures not needed

Regional public health sent specialized health teams for IPAC in LTC with Regional public health sent specialized health teams for IPAC in LTC with outbreak April 15th outbreak March 7th

Aligned threshold of outbreak with BC April 15 Revised threshold of outbreak in March

Formal guidance to test all staff and residents April 22nd Screened asymptomatic residents in homes with outbreaks starting in March

All staff and visitors to wear masks April 8th All staff and visitors to wear masks March 25th

Visitor restrictions March 13 Visitor restrictions March 16

Preparation • Meet with regional partners to co-design response plans for outbreak scenarios

• Secure PPE supply and management

• Leverage third-party assessment and guidance to ensure IPAC adherence • Test regularly Prevention • Create contact tracing protocols • Universal masking • Optimize care models • Reduce outside care providers coming into the home • Manage how often residents need to leave for care • Reduce the number of people who are waiting in hospital who need long-term care • Stabilize and reinforce – staffing People in – working conditions – psychological health and safety the workforce • Limit staff to working in only 1 higher risk environment • Provide supports to make this possible • Increase capacity through training and recruitment • Understand and mitigate community- transmission risks • Plan where to turn for assistance if there is an outbreak? Pandemic response • Plan for surge support for every home and surge capacity • Integrate surveillance methods to identify where surge capacity may be needed

• Reduce the risk of cross-infection in the case of an outbreak involving residents • Stabilize clinical leadership and ensure Plan for back-up COVID-19 • Ensure all residents have access to high and non- quality primary health care that does not require them to leave the home during an COVID-19 outbreak care • Arrange for access to needed specialty care • Have up-to-date, person-centred, integrated care plans in place • Have palliative approaches to care embedded in the home’s processes and culture • Recognize and support family caregivers as essential partners in care • Develop policies regarding family presence • Consider harm reduction approaches to support Presence of family presence family • Ensure appropriate infrastructure, supplies, and policies are in place • Create alternate plans to ensure family caregiver care and services normally provided are not compromised if family caregivers are not permitted in the home