Rapid response to a quickly evolving pandemic was critical to keep residents and those who provide care in long-term care (LTC) safe. Two Ontario-based LTC homes, Perley Health and peopleCare Communities, share key aspects of their pandemic response that left both homes well positioned to partner in the Strengthening Pandemic Preparedness in Long-Term Care rapid response research program (HEC 2022a). To share lessons learned and generate evidence around practical solutions to mitigate future outbreaks, Perley Health and peopleCare Communities identify key considerations to enhance quality of care and quality of life for LTC residents now and in the future.

Key Takeaways

• Adequate pandemic preparation allowed Perley Health and peopleCare Communities to rapidly adapt to the changing pandemic environment. Strong leadership facilitated quick responses to potential outbreaks, reinforced communication channels and advocated for personal protective equipment and testing supplies.
• Partnership between researchers and long-term care (LTC) homes provides an opportunity to work through organizational-level challenges and ensure that interventions are designed to fit within current workflow processes and systems.
• Although the Strengthening Pandemic Preparedness in Long-Term Care research program built research capacity within the LTC sector, longer-term and sustained solutions will require new policies reflecting what has been learned through this initiative to enhance quality of care and quality of life for those living in LTC.

Introduction

During the first wave of the COVID-19 pandemic in 2020, the impacts of the virus were significant in hospitals and long-term care (LTC) communities. As leaders within LTC homes caring for residents with complex health needs, who are more vulnerable to severe illness, we were determined to take quick and decisive action to keep our residents and homes safe, to keep everyone informed and to support quality of life during this challenging time.

At our LTC homes, Perley Health in Ottawa, ON, and peopleCare Communities, headquartered in Waterloo, ON, previous work in pandemic preparation allowed us to respond quickly to the ever-evolving challenges brought about by COVID-19. Yet as the pandemic continued to unfold, we quickly recognized that the LTC sector was in dire need of practical solutions to mitigate the impacts of future outbreaks and to keep residents, families, caregivers and staff safe from COVID-19. We felt that our LTC homes were well positioned to partner in the Implementation Science Teams – Strengthening Pandemic Preparedness in Long-Term Care rapid response research program (HEC 2022a) and we joined a broader community of over 90 LTC homes committed to the implementation and evaluation of policies and practices to strengthen pandemic preparedness.

This program brought evidence and research capacity to LTC homes. It helped us understand how to focus our resources and what strategies to implement now as well as in the future. As members of the research team, our voices were not only heard, but we were also equal partners at the table and helped contextualize the research within the reality of LTC. Our partnership with the implementation sciences teams (ISTs) contributed to success within each individual team and to the program more broadly. In this article, our two LTC homes share our responses to the pandemic, the lessons learned from it and common issues that emerged. We also discuss implications of the IST research within each of our LTC homes and share suggestions as to how we can move forward together for a stronger LTC system.

It is important for us to acknowledge that the following reflects our experiences and perspectives, and we recognize that across Canada, individual LTC homes' involvement with the pandemic and with the research program varies.

Background

Perley Health

Perley Health is a unique and innovative community that empowers seniors and veterans to live life to the fullest. Home to more than 600 seniors and veterans in LTC care and in independent apartments, Perley Health provides a growing number of clinical, therapeutic and recreational services to residents, tenants and people from across the region. One of the largest and most progressive LTC homes in Ontario, Perley Health is also a centre for research, education and clinical innovation. The Perley Health Centre of Excellence in Frailty-Informed Care conducts and shares the practical research needed to improve care.

peopleCare Communities

As a third-generation family-owned and operated organization, peopleCare Communities' compassionate and skilled team is dedicated to supporting individualized lifestyles in a welcoming community that enhances the quality of life for all the people involved. We believe that no matter where you live, it is the presence of family that makes a home feel like home. With an ingrained appreciation for our families and their many contributions in our homes, families are true caregiving partners with our teams and engaging with them is always top of mind.

Pandemic Preparation

With a well-established Infection Prevention and Control (IPAC) team, Perley Health was on high alert in preparation for the COVID-19 pandemic, although we could have never anticipated the magnitude and its extraordinary impact on our community and home. Preparations began in advance of the pandemic and included a strong leadership team, a committed workforce and a supportive board of directors. Regular communication with regional partners also helped with information-sharing and collective problem-solving. An established business continuity plan allowed quick redeployment when needed with "just-in-time" training and support. However, we knew more would be needed to help our LTC home navigate the uncertainty of the pandemic.

Early in the pandemic, Perley Health reviewed literature related to leadership in times of crisis. Five principles emerged that guided our work: demonstrate compassion, be agile, distribute authority, be transparent and prioritize psychological health and safety. With the official declaration of the COVID-19 pandemic on March 11, 2020, daily command team meetings were initiated. Members of the management team were brought together to share information (such as changing health measures), solve problems in real time and be proactive about solutions and "what-if" scenarios (e.g., the purchasing of a decontamination machine for personal protective equipment [PPE]). These meetings also gave us an opportunity to review the five principles guiding our work with both our leadership team and work teams.

Operationally, significant measures were taken to mitigate risk. Another team member was added to the IPAC team to support employee health. Responsibilities for this role included answering staff questions, performing contact tracing, vaccine administration/tracking and organizing testing clinics, among others. The IPAC team expanded their coverage to seven days per week to help manage the increased workload. Perley Health initiated surveillance COVID-19 testing for all residents and staff leading to the establishment of a process for mass testing in the home. An isolation unit was earmarked for COVID-19–positive resident cases and cohorting began for both residents and staff. The isolation unit proved to be effective with the Therapeutic Recreation and Creative Arts staff, Psychogeriatric and Behavioral Support staff and a dedicated team of personal support workers, nurses and physicians supporting person-centred care.

Perley Health leveraged technology for temperature checks and screening using a customized application. Eventually our screening process went electronic (a mobile application) and was routinely tailored to our changing needs. For those without devices or who preferred not to use them, we always had the option of verbal screening and devices on-site to accommodate them. Overall, technology has streamlined our approach to screening and reduced the time it would take to screen people compared to only using verbal and paper-based approaches.

Upon reflection, it is easy to document a list of key actions taken to prepare and respond to the pandemic but these new practices and the overall response took an incredible amount of dedication from staff across the organization.

People in the Workforce

Perley Health prioritizes a "people first" approach in its organizational strategy. The strategy commits to honouring healthcare workers by prioritizing their well-being and professional growth and investing in recruiting, developing and retaining people dedicated to enriching the lives of older adults. This priority is supported by a robust health human resources strategy and workplan focused on the employee experience, talent acquisition and enabling human resources infrastructure.

During the pandemic, Perley Health introduced a Psychological Health and Safety program with key initiatives and supports targeting employees' mental, physical and social fitness. Training staff in the areas of resilience, end-of-life care with COVID-19 and practice changes related to COVID-19 were priorities and required a champion model with an "all-hands-on-deck" approach. This meant that all staff, regardless of the nature of work, were expected to be present on site and ready to help where needed.

Despite these efforts, Perley Health, like other homes, was severely impacted by staffing shortages (this is an ongoing challenge in LTC and exacerbated by the pandemic, even today). By July 2020, we had lost over 100 staff members due to either restrictions (i.e., staff were only able to work in one LTC or retirement home) or personal reasons (i.e., childcare, health concerns, etc.). We also lost more than 400 volunteers who were no longer allowed on site.

Decisions had to be made regarding resident care and services, ensuring that essential care needs were met. Where possible, routines and workflows were streamlined (e.g., medication administration), and in some cases tasks were deferred (e.g., conducting annual care conferences). A business continuity plan was developed early on to plan for a variety of redeployment scenarios. To offset the impact, staff were redeployed between departments to ensure that direct care needs and staffing ratios were met. Staff were also redeployed to other units where they may not know the residents, which impacted continuity of care.

Staffing shortages also meant that staff had less time to spend with residents on other activities that contribute to quality of life, such as friendly conversations. There were fewer opportunities for residents to socialize with each other due to cohorting requirements and reduced group recreation activities. During the first phase of the pandemic, residents were unable to spend time in person with family members, friends and volunteers due to sector-wide visitor restrictions within LTC. Therapeutic Recreation and Creative Arts staff spent a significant portion of their time supporting one-one virtual visiting. While this was essential work, it did not replace the value of family presence and further eroded the team's ability to offer small group programs.

Family Presence

At peopleCare Communities, we have worked hard to support an uninterrupted presence for designated family caregivers in our LTC and retirement homes during the pandemic. Given the circumstances, our teams were challenged to think differently and our conversations changed to why we absolutely should support family presence during outbreaks. It took time and focus, but we worked together to alter our practices to make family presence possible.

Starting with digital engagement, our teams leveraged apps to support thousands of online visits. Next came creating safe, accessible and meaningful outdoor visits. We were determined to do even more.

Along with keeping families informed and engaged, when government LTC directives changed and residents were able to designate "essential" caregivers, peopleCare was ready with communication, training, PPE and unique resources, such as a caregiver pledge and "I am a Caregiver" ID badges.

This was due in part to relationships with groups such as the Ontario Caregiver Organization, which partnered with peopleCare as an early adopter of their practical resources aimed at supporting family caregivers in healthcare settings.

Perley Health was able to lean on existing communications infrastructure to engage with family caregivers, also known as essential care partners (ECPs). Regular communication was sent to families through multiple channels (emails, an automated phone messaging system, websites, posters, etc.) to update them on the constantly changing public health measures. Senior management held monthly virtual COVID-19 focused townhalls with the Family and Friends Council; a dedicated family helpline was established and emails were regularly monitored to support our connection with families and ECPs.

At different times during the pandemic, it was difficult to manage competing priorities but we knew communication and engagement with family members and ECPs was crucial. To be creative, supportive and flexible in our approach we made on-site testing and vaccination available to families, supported virtual visits, facilitated outdoor visits, enabled flexibility for family members to rotate ECP status, provided free parking and made meal kits for purchase available in our cafeteria.

We learned that timely, regular and transparent communication about the current situation explaining the "why" behind measures and not being afraid to share bad news helped maintain our credibility and establish trust. We admitted to not knowing the answer, acknowledged it when we were struggling and were open about what we were doing to resolve the issue.

Uniting Long-Term Care Homes and Research for Rapid Implementation

Perley Health partnered with two different ISTs focused on independent research projects. The first was with Annie Robitaille, whose research focused on the essential nature of family/volunteer caregiving in LTC (HEC 2022b). Our work with Robitaille involved interviewing family members and their loved ones living in LTC. We collaboratively designed the research project to ensure Perley Health had the opportunity to participate in the interviews, knowing that our presence would strengthen the relationship our home had with the ECP community.

Some of these interviews occurred on a weekly basis and we observed how family members began to look forward to these meetings. We recall one discussion with Robitaille, who shared her experience facilitating interviews as having therapeutic value for the residents and their loved ones. This work built a different type of research capacity at Perley Health. There was a collective understanding that this research project was contributing more toward solutions that everyone wants for LTC and less toward theoretical research. This also generated energy and enthusiasm to continue with future research and implementation.

The second project, led by Amy Hsu, was the implementation and evaluation of the Risk Evaluation for Support: Predictions for Elder-life in the Community Tool in Long-Term Care (RESPECT–LTC) (HEC 2022b). It is intended to support ongoing efforts to embed palliative approaches to care within existing processes and culture in LTC homes. With Hsu's team, our focus was on the implementation of the RESPECT–LTC tool into our existing workflows. One of the challenges within LTC is taking tools generated in academia and other non-LTC settings and translating them into practice. One of the benefits of implementing this tool in a research context was the ability to provide real-time feedback and troubleshoot what was working and what could be improved. We need tools that are simple and easily embedded into workflows to be successful and part of that process is having dedicated time to evaluate the tools and modify them along the way. Through this project, we were able to work through organization-level challenges and ensure integration of the tool within current workflow processes and systems.

At peopleCare, the organization partnered with the IST led by James Conklin to investigate how to further enable ECPs' safe access to their loved ones' LTC home (HEC 2022b). This research project drew on existing approaches and tools supported by the Change Foundation, Ontario Caregiver Organization, Ontario Centres for Learning, Research and Innovation in Long-Term Care (Ontario CLRI) and Healthcare Excellence Canada to initiate designated care partner programs in LTC homes. We learned a great deal through the implementation of our Family Caregiver program, including the following:

• Supporting family caregivers in LTC requires a culture shift. Staff who acknowledge the importance of family caregivers in care and quality of life may also feel unsure of the benefits of formalizing the role and apprehensive about certain care roles and tasks. It is essential that staff buy into the program and the many advantages that come from having families as care partners.
• The role families want to play depends on the nature of the relationship with their loved one. Some are comfortable providing physical care, while others are happier to engage in conversation and high-touch activities. It is also important to encourage residents and families to visit when it suits them, rather than allow visitation based on the home's routines and schedules.
• It is important to engage families in the program's purpose, and then provide targeted training that focuses on how to make every visit more meaningful. When asked for ideas on improvement, staff proposed regular "huddles" with the family caregiver and the care team at the start of each visit to offer updates on the resident's health conditions, mood and behaviours.

There are now over 1,150 designated family caregivers at peopleCare. In any given week, we are supporting hundreds of these care partners to safely spend precious time with their loved ones in the home. We recognize the incredible contributions they make as members of the care team. Currently, ongoing work has shifted toward evaluation. To do this, we are working with Ontario CLRI to evaluate our Family Caregiver program with the goal to identify what is working well and where enhancements could better support residents and integrate families into the community of the home.

Looking Toward the Future

Looking to the future, Perley Health believes it is important that the health system learn from what did not go well in LTC while leveraging the successes. As a centre that is committed to research and learning, we believe that evidence needs to be shared broadly to influence policy so that more LTC homes can benefit. Some of the key lessons are discussed below.

Leadership

Perley Health had a flexible leadership structure and leadership capacity in place before the pandemic; this allowed team members to fill emerging roles and take on tasks that were outside of their normal portfolio.

Relationships

Our strong relationship with families was critical to our success. This relationship is grounded in principles of person-centred care and includes good lines of communication focusing on openness and transparency. Our SeeMe program – which focuses on a shared understanding of quality of life and ensuring person-centered care – was established several years before the pandemic. This put us in a better position to understand residents' and families' needs and wishes during times of uncertainty. Importantly, this helped ensure quality of life stayed at the forefront of our decision making.

Culture of innovation, learning research and quality improvement

Perley Health is an organization committed to problem solving, trying new things and building programs and infrastructure to address our needs and challenges. This has encouraged us to build relationships with conventional and unconventional partners, including academia, the private industry and government relations networks, which we were able to leverage during the pandemic to find solutions. Examples include the following:

• When faced with a looming shortage of PPE, we were able to source supplies from China, procure a novel decontamination machine and participate in a national advisory committee to understand and spread the research supporting the decontamination technology.
• Our relationship with academic institutions allowed us to continue with safe student placements, which helped us partially alleviate staffing pressures.
• We found ways to safely bring back volunteers earlier than most homes because we had the infrastructure to do so. Through our structured volunteer program, Perley Health was able to find innovative ways to train, vaccinate and screen volunteers and find appropriate roles for them to fill. This also helped address the quality-of-life issue for residents as we know what an important role volunteers play in the lives of our residents.

Risk management framework

Perley Health had an existing risk management and ethical decision-making framework that helped us analyze and respond to risk. This structure was already integrated into our existing processes and made it easier to assess pandemic-related risks. As a result, we were comfortable trying new things aligned with our risk tolerance and applied this framework as challenges surfaced – for example, in re-integrating volunteers. Our daily command meetings included a standing agenda item on quality of life; this ensured that it was top of mind when weighing risks and benefits.

We also want to be part of the solution and leverage our experiences to enhance care and quality of life for residents living in LTC now and in the future. Perley Health is committed to the following goals:

• a continued focus on people first – as learned from researcher Pat Armstrong et al. (2020) that "the conditions of work are the conditions of care (p. 7);"
• acknowledging the impact of social isolation on the well-being of residents. Knowledge from research in Perley Health's Centre of Excellence in Frailty-Informed Care will be leveraged. This includes finding ways to foster meaning in life for each person and working with researchers to develop, evaluate and share best practices in person-centered care and social connection in LTC. There must be a balance of risk and quality of life as LTC is the resident's home; and
• improving relationships among those in the system and influencing policy. There is tremendous expertise in LTC and the time to listen is now.

At peopleCare, the pandemic has shown that despite any misgivings or challenges, it is possible to successfully and safely engage families to support resident care and well-being in all situations. Along with the opportunity to continue building meaning and value into our overall program and resources, we now have a pool of informed and engaged family caregivers who could be tapped, for example, to strengthen and bolster our family councils.

We also intend to build on the success of our enhanced Family Caregiver program as peopleCare explores emotion-based models of care, which is about caring for each resident as an individual. By knowing their history, wishes, likes and dislikes, we can use the information to enhance experiences, engage with them and accomplish care together in a way that is meaningful to each resident. Families have a unique insight into their loved ones. They are at the heart of knowing who that person is and who they were in their past lives.

Moving Forward

Throughout the pandemic, there has been a spotlight on the LTC sector and while in many ways this has been uncomfortable and difficult, we have an opportunity to think about how we can do things differently. While the pandemic magnified existing vulnerabilities, these challenges did not develop in weeks or months and will not all be solved in the short term. We will need long-term and sustainable solutions to long-standing vulnerabilities to reform our LTC system. Evidence and research are important components as we think of the future of LTC. With the rapidly growing number of people over 85 years of age, we need to find better ways of caring for older adults living with frailty.

The people who live and work in LTC already intimately understand impacts of social isolation on frailty, physical health, quality of life and life expectancy. We know this but we need to be enabled by policies that support flexibility in our approaches to care to ensure that all care is person centred. We are lacking people who work and live in LTC and who are engaged in identifying and solving problems in LTC. While the IST initiative has strengthened partnerships among researchers, LTC homes, residents and their loved ones and built research capacity across the sector, policy to influence longer-term reform must reflect what we learn from this initiative.

LTC homes need to work in partnership to make system-level changes. There is a wealth of expertise in LTC to be leveraged when it comes to decision making, and we deserve a seat at the table. The people living in LTC are in the last stage of life and it is essential that we support the whole journey, which requires optimizing quality of life and active end-of-life care.

Leçons tirées des partenaires des foyers de soins de longue durée pendant la pandémie de COVID-19 

Résumé 

Une réaction rapide à une pandémie qui évolue rapidement est essentielle pour assurer la sécurité des résidents des établissement de soins de longue durée (SLD) ainsi que celle des prestataires de soins qui y travaillent. Deux établissements ontariens de SLD, Perley Health et peopleCare Communities, partagent des aspects clés dans leur réaction à la pandémie, ce qui leur a permis de s’associer au programme de recherche rapide Renforcer la préparation des établissements de soins de longue durée à la pandémie (ESC 2022a). Afin de partager les leçons apprises et de générer des données sur les solutions pratiques pour atténuer l’effet d’éventuelles épidémies, les organismes Perley Health et peopleCare Communities font état de considérations clés pour améliorer la qualité des soins et la qualité de vie des résidents des SLD maintenant et à l’avenir. 

Disclaimer

This work is supported by Healthcare Excellence Canada (HEC). HEC works with partners to spread innovation, build capability and catalyze policy change so that everyone in Canada has safe and high-quality healthcare. The views expressed herein are those of the authors and do not necessarily represent the views of HEC.

HEC is an independent, not-for-profit charity funded primarily by Health Canada.

The views expressed herein do not necessarily represent those of Health Canada. Unmodified use or reproduction of this publication is permitted within Canada for non-commercial purposes only. This publication is provided "as is" and is for informational/educational purposes only. It is not intended to provide specific medical advice or replace the judgment of a healthcare professional. Those preparing and/or contributing to this publication disclaim all liability or warranty of any kind, whether express or implied.

This work is supported by the Canadian Institutes of Health Research (CIHR). At CIHR, we know that research has the power to change lives. As Canada's health research investment agency, we collaborate with partners and researchers to support the discoveries and innovations that improve our health and strengthen our healthcare system.

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