Recent experience with the outbreak of severe acute respiratory syndrome (SARS) in Canada and the global threat of the H5N1 virus (avian "flu") have increased the appetite for and urgency of pandemic planning as a policy issue. The healthcare setting is one of the most important areas to prepare for such an event, and it is crucial that discussions around doing so include all settings in which care is delivered. As the home and community care sector is increasingly utilized and likely to be relied upon even more during a pandemic, addressing the challenges to occupational health and safety uniquely faced by this sector will be vitally important to the entire health system. A pandemic plan that does not consider healthcare outside of the institutional setting is incomplete and will be likely to fail. This commentary outlines the challenges to providing care in the home and community that must be considered in any plan designed to deal with a pandemic on a system-wide level.
Pandemics are a part of the public health landscape and a threat to people around the world. Governments worldwide have engaged healthcare leaders in their respective countries to develop pandemic plans, and Canada has followed suit. Considering the key role played by the home and community care sector in addressing the needs of vulnerable populations, such as the elderly, post-acute patients, the disabled and the chronically ill, this sector should be heavily involved in pandemic planning. Those most at risk from pandemic infection are often immunocompromised, the same population often receiving home and community care.
Victorian Order of Nurses (VON) Canada has used the lessons learned from the outbreak of severe acute respiratory syndrome (SARS) to develop the VON Canada Pandemic Plan (2006). VON is the country's largest non-profit organization delivering innovative, comprehensive health and social care to Canadians and influencing the development of health and social policy; it has been doing so for more than 110 years. VON's pandemic plan was influenced by its holistic approach to healthcare, looking beyond institutional settings to provide a set of guidelines to protect healthcare workers, volunteers, caregivers and patients in the home and community care sector.
As stated by Silas, Johnson and Rexe, occupational health and safety should play a major role in pandemic planning. VON agrees completely with this position, and would also suggest broadening the scope to include the health and safety needs of unpaid caregivers and volunteers as the home and community care sector relies heavily on these groups to deliver essential services.
Planning for a Pandemic: The Home and Community Care Sector's Vital Role
Although the general public often thinks of pandemic planning in terms of institutional settings, such as hospitals and long-term care homes, in reality any setting where healthcare and services are delivered is at risk of contamination. For example, during the SARS outbreak in 2003, four paramedics in Toronto contracted SARS (Farr and Mcintyre 2003). It is unknown whether they contracted the virus in a patient's home, in an ambulance or at a healthcare facility. In 72% of all the probable and suspected SARS cases, individuals contracted the syndrome in healthcare settings; in the remaining 28%, individuals were infected in the community (D'Cunha 2003). Therefore, since pandemics know no boundaries and can infect people in any setting, all parts of the healthcare system should have a plan to respond effectively to decrease the risks to workers, patients and the public at large.
Finally, a key component of any comprehensive pandemic plan is education. Educating people prior to a pandemic is essential in order to minimize risk and prevent further contamination and social chaos. An education strategy requires the involvement of settings where people congregate, such as community organizations and religious institutions.
Home and Community Care
The home and community care sector is one of the fastest-growing parts of the healthcare system. Since 1995, home care use has increased 60% in Canada and is expected to continue to grow, driven by an aging population, increased demand by patients to receive care in their homes, improved technology and bed closures in health institutions (Canadian Home Care Association 2004). Yet, the dollars have not followed the growth.
Canada's commitment to the sector ranks poorly internationally, spending 0.17% of its gross domestic product on home care, among the lowest of the countries in the Organisation for Economic Co-operation and Development ("No Place like Home" 2005). These data suggest that the Canadian home and community care sector is undervalued by decision-makers.
If a pandemic were to occur on Canadian soil, reliance on an already over-stretched home and community care sector would increase. A pandemic would likely limit Canadians' access to hospitals, long-term care homes and other healthcare institutions due to the limited number of beds and efforts to avoid further spread of the virus. Patients would be forced to receive care in their homes and communities, regardless of the complexity of their illness or condition.
VON's Pandemic Plan
Recognizing the importance of planning for health emergencies, VON has made pandemic planning a priority. Due to the nature of VON's work and its deep commitment to its patients and their caregivers, its staff and its volunteers, VON felt it was critical that a pandemic plan be created to guide the response of VON sites and protect its employees, volunteers and patients in the case of a health emergency.
The VON Canada Pandemic Plan (2006) was reviewed by external experts, who recommended revisions to the human resource portion of the plan to reflect the current nursing shortage, the potential decrease in available staff during a pandemic and the possibility of some staff refusing to work if a pandemic were to occur. It was recognized that these human resource issues could significantly impede VON's ability to serve patients and communities and had to be taken into account. Once finalized, national education sessions were conducted for VON sites.
Challenges Faced by Home and Community Care in Responding to and Preparing for a Pandemic
Delivering healthcare in the home can often be more challenging for healthcare providers than doing so in other settings. The typical home care setting involves the patient, the professional care provider and other stakeholders such as family and friend caregivers and volunteers. This means that there is a multitude of untrained care providers, which makes decisions and delivery of care much more challenging than when conducted in a regulated environment such as a hospital setting (Lang et al. 2006). In a pandemic, these caregivers would become progressively more necessary and the support they receive from professionals would diminish as the system would become increasingly overwhelmed. Therefore, when considering the health and safety of healthcare providers, the precautions cannot be limited to paid providers alone. Further, because of their mobility, family and friend caregivers can be carriers of illness leading to further social and economic repercussions. Therefore, it is important that this dynamic also be addressed during pandemic planning.
Another important point to highlight is that not all people receiving home and community care have similar needs. One subpopulation that would be particularly vulnerable during a pandemic is the chronically ill. To help mitigate the effects of illness on this group of people, it is essential that providers and communities have a mechanism in place to help identify the vulnerable and prevent them from being exposed to further illness. People's needs are complex, and a plan to respond to their needs must reflect this reality.
Lastly, the physical environment of the home also provides challenges that are relevant to pandemic planning. The typical home is not designed for healthcare delivery. Healthcare providers in the home have limited access to technology and supplies, restricted ability to enact policies and procedures to mitigate risks and less contact with colleagues and supervisors than their colleagues in other sectors (Lang et al. 2006). These risks have implications not only for patient safety but also for occupational health and safety, especially in a pandemic. If not addressed within the planning phase, these risks could be the cause for the failure of any plan. Pandemic planning must take into account the need to mitigate both patient and provider risks in diverse, uncontrolled and unregulated environments. There is a clear link between patient safety and caregiver safety. If the care provider (paid or family/friend) is not safe, then the client is likely not safe (Lang et al. 2006).
The Aboriginal Population
Aboriginal Canadians bear a disproportionate risk of injury and illness compared with non-Aboriginals. Mortality rates for the Aboriginal population are almost twice those of the whole population of Canada, for both men and women (Caron 2005). Among the factors identified that might be contributing to this situation are the need for better emergency treatment for Aboriginal patients, a lack of access to timely and adequate levels of healthcare in rural and isolated regions and a lack of culturally safe care (Caron 2005). Extrapolating from this experience, it is likely that the Aboriginal population would also face a pandemic with inadequate and/or inappropriate healthcare. Therefore, no pandemic plan can ignore the needs of isolated communities and, in particular, the disproportionate risk faced by the Aboriginal population.
Health Human Resource
The home care sector faces unique issues not confronted by the acute and long-term care sectors. Having been largely ignored by the healthcare system for years, it experiences chronic underfunding of home care programs, staff and services. This constant underfunding has led to a persistent problem with the recruitment and retention of health human resources, affecting not only regulated health professionals but also unregulated workers such as personal support workers, who provide much of the front-line care in the sector. Employees who work in the home care sector often do so on a casual or part-time basis and, of necessity, work for multiple employers, both within and outside the home care sector. Thus, from an infection-control perspective, there is a real possibility of multiple exposures and cross-contamination of environments in the home care sector, putting both health workers and their clients at risk. This migration across sectors and sites is especially worrisome when one considers that a significant proportion of the population currently receiving home care services are frail persons with a number of complex co-morbid conditions (Lang et al. 2006). Pandemic planners must take this population into account and should consider technology options that could facilitate ongoing care for vulnerable patients in the home during a pandemic. For example, distance monitoring and case conferencing through teleconference could minimize the need for face-to-face visits with health workers.
An additional factor to consider related to occupational health and safety is the thousands of small companies composed of unregulated healthcare workers providing services to patients across Canada. Often these companies have limited capacity to plan for a pandemic, yet they will be relied on to provide additional services if one should occur. This group of home and community care organizations must be included in pandemic planning and educational sessions to ensure they provide optimal care to their patients and avoid further spread of illness.
Silas, Johnson and Rexe advocate that, based on the precautionary principle, the N95 respirator should be the minimum standard of protection for nurses and other healthcare workers. Whether the N95 respirator becomes the tool of choice or not, the fundamental question that must be addressed is, who will pay for these safety precautions? As noted above, the home and community care sector has been underfunded for years. Home care providers do not receive global budgets from large single funders. Their funding sources are sporadic and multiple and do not include much, if any, in the way of discretionary dollars. Without additional sources of funding, home healthcare providers will be unable to stockpile even basic supplies such as hand sanitizers and surgical masks, let alone more sophisticated and expensive devices such as the N95 respirator. Given the increased reliance on home and community care during a pandemic, it would be unreasonable and unwise for governments to ignore the real need for emergency funding for home care providers that will enable them to give their workers adequate protection during a pandemic.
In the event of a pandemic, the home and community care sector would be expected to alleviate some of the pressure on other parts of the healthcare system. If the sector is to respond adequately, it must be involved in the planning. There are many challenges that could impede the home and community care sector's ability to respond effectively and efficiently to a pandemic. Silas, Johnson and Rexe are quite right that occupational health and safety must be a key part of pandemic planning, but this concern should extend not only to paid caregivers but also to volunteers, family/friend caregivers and unregulated workers who are vital in the delivery of home care. Additionally, patient safety and financial and health human resource pressures on the home and community care sector must be considered by pandemic plans if these plans are to succeed.
The home and community care sector does not work in isolation. Although this paper highlights the sector's essential role, the authors recognize that all sectors and levels of government contribute to the health and well-being of Canadians. It is important to remember, for example, the key role local governments - municipalities and band councils - play in managing pandemics and ensuring Canadians have continual access to medical and other essential supplies, such as food and water. However for these supports to be available, appropriate funding must be allocated at the local level. The report Learning from SARS: Renewal of Public Health in Canada states that a key requirement for managing future health emergencies is a collaborative framework (Health Canada 2003). VON supports this recommendation and fully advocates for the inclusion of all sectors and levels of government at the table, working together to ensure the best health outcomes for Canadians.
About the Author(s)
Judith Shamian, RN, PhD, LLD(hon), DSci(hon)
President and Chief Executive Officer
Victorian Order of Nurses (VON) Canada
Teresa Petch, BA, MHSc
Freya Lilius, BA
Esther Shainblum, BA, LLB, LLM
Rita Talosi, RN, BSc, MSN
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