Nursing Leadership

Nursing Leadership 33(3) September 2020 : 20-28.doi:10.12927/cjnl.2020.26322
Special Focus: Introduction To Crisis Leadership

Community Care and COVID-19: A Case Study

Barbara Mildon

Abstract

Community Care City of Kawartha Lakes provides primary care through its Community Health Centre, a range of hospice services and numerous community support services. Along with other essential service providers, our organization has continued to operate throughout the pandemic. As a community-based health services provider, we recognized the imperative and the privilege for our organization and the larger home and community care sector to support individuals, especially those most vulnerable due to health status, socio-economic circumstances or isolation, to safely remain at home during the pandemic, in compliance with public health directives. This article describes the strategies and approaches we implemented along with reflections on the leadership practices and principles that emerged. It does not purport to be an exemplar for crisis management of the COVID-19 pandemic. Rather, it seeks to draw attention to the contributions made by community-based organizations and potentially serve as a case study for debate.

Introduction

When the COVID-19 pandemic began, I was nearly two years into my role as chief executive officer for our not-for-profit primary care and community support services organization. As news of the impending pandemic intensified, my experience and learnings from the 2003 severe acute respiratory syndrome (SARS) epidemic resurfaced, accompanied by acute awareness of the imperative for our organization to do everything possible to enable our clients to stay safely at home in order to flatten the virus transmission curve. This article does not purport to provide an exemplar for crisis management of the COVID-19 pandemic to date. Rather, it seeks to draw attention to the contributions made by community health services providers, to share reflections on the leadership practices and principles that emerged and to potentially serve as a case study for discussion and debate.

Located 90 minutes northeast of Toronto, the City of Kawartha Lakes has a population of approximately 75,000 and a land mass of just over 3,000 km2. Our organization, Community Care City of Kawartha Lakes (CCCKL), offers primary care and wellness programs through our community health centre (CHC), affordable dental care, geriatric assessment services, hospice services and a variety of community support services, including Meals on Wheels, community dining, adult day programs (ADPs) and personal support services. Governed by a volunteer community board comprising 12 directors, CCCKL employs approximately 190 staff members and relies on more than 400 volunteers to support service delivery. Approximately 75% of our annual budget comes from the Central East Local Health Integration Network, now evolving into Ontario Health East.

COVID-19: Early Days

On March 11, 2020, the World Health Organization designated COVID-19 a global pandemic (Young 2020), and on March 12, 2020, Ontario Premier Doug Ford announced that publicly funded schools would close for two weeks following the March break (Stone et al. 2020). Building on the screening practices we had already established, these announcements triggered implementation of our COVID-19 incident management structure (committee). Firestone (2020) identified a crisis as a "situation that develops quickly and requires a response from a person or an organization in order to mitigate the consequences" (p. 2). The sudden need to close down or reduce core services owing to COVID-19 clearly called for a response, and the committee proceeded to develop and implement key strategies to lead the organization through the pandemic (Box 1).


Box 1. Key strategies
  1. Centralized Incident Management System/COVID Coordinating Committee
  2. Communicate, communicate, communicate
  3. Visible leadership (senior team on site; Zoom meetings)
  4. Supporting clients: Outreach and reinventing care delivery models
  5. Supporting staff: Initiatives to promote health and well-being
  6. Financial management: Cash flow management, employment status review, applying for new funding sources
  7. Sustaining governance processes

 

Strategies

Communication

One of the lessons taken from the SARS epidemic of 2003 was the imperative for frequent and clear communication to staff and stakeholders – a theme spoken to in more recent literature by AlKnawy (2019) and Deloitte (2015). Working with content generated during the daily committee meetings, on March 13, 2020, our communications leader began producing a daily newsletter distributed to all staff, volunteers and, at their request, our board of directors. We took care to celebrate victories and highlight rays of light (Haudan 2020) by including an "encouragement" section, sharing positive feedback, team photos and inspiring quotations. Our managers and directors implemented regular team huddles via Zoom to support staff, answer questions and assist in problem solving. We kept the public updated through our website and social media platforms, along with ads placed in local papers.

Infection Prevention and Personal Protective Equipment

Information about personal protective equipment (PPE) use changed frequently as the pandemic evolved, and providing clear guidelines and quick responses to questions and concerns from staff became essential. PPE protocols were included in the daily newsletter and further interpreted by our clinical lead as needed. Our mobile workforce (e.g., drivers, personal support workers [PSWs]) gathers PPE supplies from offices at various geographic locations, and ensuring PPE availability was a priority. Our clinical leader accepted responsibility for managing the PPE supply and conducted a daily inventory at each site. With occasional contributions of PPE supplies, we have been successful in meeting the PPE needs of our staff through the pandemic to date.

Clients needing essential medical treatments (e.g., dialysis, cancer treatment) and travel to and from the hospital continued to be served. Drivers wore PPE in excess of public health guidelines from the start of the pandemic, a practice validated as PPE guidelines evolved, and protective screening was eventually installed in the van between the driver and passenger. Referral sources including the hospital or long-term care home reported when one of our employees may have been exposed to a COVID-positive client. We supported those employees in accessing COVID testing and other needed resources; for example, one employee was provided with a digital thermometer. All staff consistently followed prescribed screening and PPE protocols, and so far, to the best of our knowledge, none of our employees have tested positive for COVID-19.

Reinventing Care Delivery Models

Public health and ministry directives to stay at home put an abrupt end to group programs such as adult day, wellness groups and community dining. Finding ways to assess the status and needs of clients and caregivers in those programs became an immediate priority, and weekly telephone calls to clients were implemented. As was widely publicized, getting groceries and essential supplies was an issue for many isolated seniors. In response, the manager of our ADP and her team reinvented their care delivery (Box 2), becoming "The Care Crew" and personally shopping for and delivering groceries and supplies to clients' homes. One issue was how the client would pay for the items. Cash was not universally accepted, even if the seniors had it available. As well, even a pandemic did not change our policy of prohibiting staff from using a client's debit or credit card. The solution was for the manager to provide information to the client or relative about setting up an account with a grocer so that purchases could be securely billed to their credit card. Feedback on the service was eloquent – one caregiver sent a donation and note thanking the Care Crew for supporting her father's weekly grocery needs as she was prohibited from doing so. An employee found a card waiting at the grocery drop-off spot describing the Care Crew as "angels helping the vulnerable." It was not only seniors who were vulnerable to the effects of the pandemic; single mothers and chronically ill adults requested help with essential supplies, such as groceries or hygiene products, and our staff used discretionary funds to purchase and deliver those items to the extent possible.

Box 2. Reinventing the Adult Day Program
Before COVID-19
Groups of up to 25 seniors/vulnerable adults congregating for structured activities, socialization and wellness; associated with caregiver relief

During COVID-19
  1. Real-time phone calls to offer support and elicit needs
  2. "Care crew": Staff did shopping and other essential errands for clients while adhering to COVID-19 precautions
  3. Outreach to address client/caregiver loneliness and isolation — staff prepared and distributed care packages monthly
  4. "Social isolation and caregiver relief program": PSWs and registered practical nurses provided in-home service (no fee while grant funding in place) to engage with the client and provide caregiver respite
  5. Virtual Adult Day Program developed and implemented


 

 

ADPs engage seniors through structured activities, promote socialization and offer caregivers respite. In the absence of those programs, as pandemic restrictions continued, staff detected increasing isolation and caregiver exhaustion during the check-in calls. In response, staff prepared care packages containing "boredom buster" activities (puzzles, books), comfort items (hand sanitizer, lotion) and edible treats for each ADP client. The first drop-off was in April 2020, with three employees (all wearing masks) driving over 200 km in one day to deliver more than 30 packages to homebound clients/caregivers. With permission, they took photos of the clients through windows and doorways, capturing heart-rending expressions ranging from excitement and delight to loneliness and despair. To expand distribution of the packages to all ADP clients, mail distribution continued monthly thereafter.

To further address caregiver exhaustion, the social isolation and caregiver relief program was created. Through this program, registered practical nurses and PSWs (wearing appropriate PPE) go into homes for up to four hours, engage directly with the client and relieve the caregiver. Demand for this service, which was initially provided free of charge due to special COVID grant funding, grew quickly.

Employees working from home reinvented care delivery using virtual tools. Primary care physicians and nurse practitioners offered a mix of in-person care and virtual care visits enabled by the PS Suite Electronic Medical Record. Recognizing that isolation and the inability to be with loved ones at the time of death or to gather family and friends at a funeral could exacerbate grief, hospice staff quickly moved to virtual grief counselling. One-to-one coaching/teaching sessions were provided to help participants learn how to navigate the virtual platform, and each signed a newly developed privacy/confidentiality statement. Zoom meetings were also implemented for social wellness group members and were enthusiastically attended.

Addressing Employee Fatigue and Conveying Appreciation

Burke (2020) identifies stamina as one of the leadership lessons taught by the COVID pandemic and emphasizes the need for attention to the mental and physical health of the workforce. I had learned those lessons from the SARS epidemic, having witnessed employee burnout and exhaustion – and the SARS epidemic was far shorter than the COVID-19 one has been. Throughout COVID-19, our staff have experienced rapid change in protocols and program delivery models, high levels of ambiguity and complexity in decision-making and increased workloads. For example, our Meals on Wheels program increased by close to 30%. The added workload was absorbed by redeployed staff members because most of our volunteers were seniors required to isolate at home. A scheduled four-day Easter break in April allowed many employees extra time to rest. However, by mid-May 2020, fatigue was plainly evident again, and an additional paid day off was granted to all staff over the long weekend. This strategy addressed fatigue, boosted morale and conveyed appreciation. Thank-you packages containing snacks, juice boxes and a thank-you note were also distributed to staff. Our board of directors convened a staff-appreciation task force, ultimately working with a local restauranteur to provide all 140 active staff with a gift certificate for a meal for two, including home delivery to those living locally. The gift certificate and a thank-you letter were mailed to employees' home address. This gesture supported a struggling local business while also conveying meaningful appreciation and recognition to staff.

Workforce Management and Governance

In keeping with ministry and public health directives, we enabled as many employees as possible to work from home. The information technology staff were especially busy in the early days of the pandemic as they deployed equipment and coached staff on set-up and remote connectivity. AlKnawy (2019) asserted that ensuring visible senior leadership during the crisis instills confidence in staff and demonstrates that the situation is under control. To that end, I continued to work in my usual office location, as did most management team members, and we used Zoom for meetings as another way to be visible to staff.

Operational Management and Governance

Reducing loss and keeping things operating as normally as possible are the goals of crisis leadership according to Klann (2000). Cash flow and the ability to meet payroll and operating costs were concerns at the outset of the pandemic. Two board directors had experience in cash flow management and joined finance representatives in forming an ad hoc task force to evaluate cash flow and provide me with a weekly report. This intervention reduced risk and increased organizational capacity through new management tools. Tracking COVID-related expenditures was also initiated using a new cost centre to be ready for future expense reporting/reconciliation. With program closures and the need to redeploy staff members to duties previously filled by volunteers, we reviewed employment status for every staff member. We did not have work for all of our casual staff and phoned them to discuss options and programs, including the Canada Emergency Response Benefit (CERB). We continued recruitment, filling two director vacancies early in the pandemic, and sustained monthly board meetings using Zoom, in keeping with best practices during a crisis.

Key Challenges

Information Overload and Navigating Government Initiatives and Grant Opportunities

Early in the pandemic, the volume of e-mails, ministry and public health directives, webinars and virtual meetings was overwhelming. Our senior management team divided up attendance at recurring meetings and was selective in what e-mails we forwarded to other team members. Having met eligibility criteria, we believed we would be remiss if we did not apply for government initiatives such as the Canada Emergency Wage Subsidy (CEWS) and the CERB to contribute to sustainability amidst uncertainty. The government initiatives required time to analyze and apply. Non-governmental funding opportunities were targeted at similar programs and initiatives (for example, Meals on Wheels, support for isolated seniors) and accompanied by challenging timelines in which to apply and/or spend the grant. Nonetheless, we are grateful beneficiaries of some of those grants.

Navigating Service Restart/Ramp-up and Staff Members' Return to Office

Decreasing or closing program delivery and enabling staff to work from home at the start of the pandemic turned out to be far easier than bringing them back to the office. Many were reluctant to return due to fear of contracting the virus. However, after more than three months, our clients needed services that could not be provided virtually, including foot care, dental care, geriatric assessments, in-person counselling and clinical care. Moreover, we had implemented all the recommended infection control measures, including (but not limited to) rearranging desks; staggering in-office days to ensure physical distance; installing Plexiglas barriers, floor markings and additional hand sanitizer stations; assigning responsibility for disinfection of high-touch surfaces; and placing masks and signage at entrances to our offices. We also hired a full-time custodian for our CHC to clean and disinfect clinical space, meeting rooms and washrooms throughout the day.

Beginning the week of June 8, 2020, we asked staff to return to the office at least two days per week to resume or ramp up services. By June 29, 2020, most services had met that goal. Middle managers were expected to return to the office full time in order to provide leadership for their teams – a requirement we recognized was at odds with widely publicized decisions by companies to continue work-from-home arrangements (for example, Scotiabank [Alexander and Duarte 2020], Google [Kelly 020] and Spotify [Aswad 2020]), with government documents (Government of Ontario 2020) also supporting ongoing work from home. Our rationale is multifaceted: first, we are a designated essential services provider with a mission to provide primary care and community support services. Second, it seems incongruent to expect our front-line staff to provide direct client care while managers work exclusively from home. Third, our front-line staff regularly travel into our offices for supplies or schedules. When the manager is absent, the opportunity is lost for spontaneous conversation, idea exchange or visual clues regarding an employee's health and well-being. Of course, the greater public good of ending this pandemic is paramount. Accordingly, we will continue to reassess this approach as we adhere to public health and ministry directives while striving to balance care and consideration for both clients and staff.

Outcomes

A key outcome for our organization is pride in demonstrating resourcefulness, resilience and determination to serve our clients throughout the pandemic. The new program delivery models are sustainable and can be further scaled up if needed. Not yet six months through the fiscal year, our financial outcomes are uncertain and will depend to some extent on decisions made by our funders. However, we have taken all opportunities to keep our financial position strong. Our governance processes were maintained, and we remained visible in our community (including participating in a municipal virtual COVID-19 town hall), with no reputation risks identified to date. Clients have expressed appreciation for our services, and many staff members have identified feeling appreciated and acknowledged. Staff members who were normally not connected had opportunities to work together, and the COVID Coordinating Committee provided a bonding opportunity for the entire management team. One of our managers observed that the pandemic has brought us closer together as an organization – an outcome that can definitely be celebrated.

A Call to Action

The imperative for the delivery of home and community support services to enable individuals to stay home is not a discovery born of this pandemic. The sector has long struggled for visibility and equity in a hierarchical healthcare system. Community support services such as Meals on Wheels, transportation and community dining are especially vulnerable to being overlooked. Successive reports and editorials have strongly advocated for accessible and comprehensive home and community care services (e.g., Canadian Home Care Association 2011; Poirier et al. 2020). Moreover, a recent study found that one in nine individuals newly admitted to long-term care could have been maintained at home if sufficient home and community care services had been provided (Canadian Institute for Health Information 2020). This finding is tragic for individuals and families and a failure of our healthcare system. In Ontario, health system reform through the development of Ontario Health Teams has begun. We must seize this opportunity to transform home and community care, inclusive of community support services, from an afterthought to the linchpin of the healthcare system.

About the Author(s)

Barbara Mildon, PhD, RN, CHE, Chief Executive Officer, Community Care City of Kawartha Lakes, Lindsay, ON, Editor, Policy and Innovation, Canadian Journal of Nursing Leadership

Correspondence may be directed to: Barbara Mildon by e-mail at bmildon@ccckl.ca

Acknowledgment

The author extends deep thanks to the staff, volunteers and board of directors of CCCKL and the Community Care Foundation (Kawartha Lakes) for their unwavering commitment to clients and their efforts throughout the pandemic. Thanks also to Conquer COVID and Ross Memorial Hospital for donations of PPE and to our primary funder, the Central East Local Health Integration Network/Ontario Health East.

References

Alexander, D. and E. Duarte. 2020, July 28. Scotiabank Headquarters Employees to Work from Home until 2021. Financial Post. Retrieved September 18, 2020. <https://financialpost.com/news/fp-street/scotiabank-headquarters-employees-to-work-from-home-until-2021>.

AlKnawy, B. 2019. Leadership in Times of Crisis. BMJ Leader (1)3: 1-5. doi:10.1136/leader-2018-000100.

Aswad, J. 2020, May 21. Spotify Tells Employees They Can Work from Home until 2021. Variety. Retrieved September 18, 2020. <https://variety.com/2020/music/news/spotify-employees-work-from-home-1234613095/>.

Burke, T. J. 2020, April 17. Crisis Leadership Lessons from COVID-19. Retrieved July 27, 2020. Gowling WLG. <https://gowlingwlg.com/en/insights-resources/articles/2020/crisis-leadership-lessons-from-covid-19/>.

Canadian Home Care Association. 2011, April. Access to Quality Health Care: The Home Care Contribution. Retrieved August 14, 2020. <https://cdnhomecare.ca/wp-content/uploads/2020/03/Access-to-Quality-Health-Care-CHCA-June-2011-English.pdf>.

Canadian Institute for Health Information. 2020, August 6. 1 in 9 Newly Admitted Long-Term Care Residents Potentially Could Have Been Cared for at Home. Retrieved August 21, 2020. <https://www.cihi.ca/en/1-in-9-new-long-term-care-residents-potentially-could-have-been-cared-for-at-home>.

Deloitte. 2015. Crisis Leadership: Five Principles for Managing the Unexpected. The Wall Street Journal. Retrieved July 24, 2020. <https://deloitte.wsj.com/riskandcompliance/2015/07/06/crisis-leadership-five-principles-for-managing-the-unexpected/>.

Firestone, S. 2020, May 29. What Is Crisis Leadership? Biblical Principles of Crisis Leadership 2020: 7–21. doi:10.1007/978-3-030-44955-1_2.

Government of Ontario. 2020, July 13. A Framework for Reopening Our Province: Stage 3. Retrieved July 14, 2020. <https://files.ontario.ca/mof-framework-reopening-province-stage-3-en-2020-07-13-v2.pdf>.

Haudan, J. 2020. Leading Your People in Times of Crisis [blog post]. Root Digital Experiences. Retrieved July 20, 2020. <https://www.rootinc.com/blog/leading-your-people-in-times-of-crisis/>.

Kelly, J. 2020, May 21. Google Employees Will Work from Home through Next Summer. Forbes. Retrieved September 18, 2020. <https://www.forbes.com/sites/jackkelly/2020/07/27/google-employees-will-work-from-home-through-next-summer/#1d52dc8f3268>.

Klann, G. 2000. Crisis Leadership: Using Military Lessons, Organizational Experiences, and the Power of Influence to Lessen the Impact of Chaos on the People You Lead. Center for Creative Leadership. Retrieved July 23, 2020. <https://www.ccl.org/wp-content/uploads/2020/03/crisis-leadership-center-for-creative-leadership-guidebook.pdf>.

Poirier, J.-A., S. Sharkey, and S. Cottrelle. 2020, February 19. Ontarians Need a Bolder New Approach to Home Care. The Toronto Star. Retrieved September 19, 2020. <https://www.thestar.com/opinion/contributors/2020/02/19/ontarians-need-a-bolder-new-approach-to-home-care.html>.

Stone, L., J. Gray and C. Alphonso. 2020, March 12. Ontario to Close All Public Schools for Two Weeks after March Break. The Globe and Mail. Retrieved September 19, 2020. <https://www.theglobeandmail.com/canada/article-ontario-to-close-all-public-schools-for-two-weeks-after-march-break/>.

Young, L. 2020, March 11. WHO Declares Novel Coronavirus Disease a Pandemic. Global News. Retrieved September 19, 2020. <https://globalnews.ca/news/6660863/who-coronavirus-pandemic/>.

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