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Read the transcript: Donna Duncan on Long-Term Care Before, During and Post-COVID-19

The Ontario Long Term Care Association’s Wave 2 Action Plan for long-term care consists of 11 elements that aim to ensure long-term care homes have what they need moving forward to prevent and contain COVID-19. In this episode, Donna Duncan, Chief Executive Officer of the Ontario Long Term Care Association (OLTCA), joins Patrick Nelson to look back at lessons learned from the first wave of the pandemic and look forward to the measures needed to protect Ontario’s seniors and those who care for them.

Donna Duncan is the CEO of the Ontario Long Term Care Association (OLTCA); the largest association representing long-term care providers in Canada. OLTCA represents almost 70% of Ontario’s 637 long-term care homes, located in communities across the province. These homes provide care and accommodation to more than 70,000 residents annually. Donna is a passionate and experienced broader public sector executive and board director, with deep expertise in defining and leading successful transformational organization and system change initiatives in health care and post-secondary education. Donna has served as the interim CEO of The Ontario Caregiver Organization and, from 2010-2017, served as the President and CEO of the Hincks-Dellcrest Centre, a large children’s mental health treatment, research and teaching centre.

Listen to the podcast episode here.

Patrick Nelson: Hello listeners, my name is Patrick Nelson and I am a Principal here at Santis Health. Today I am joined by CEO of the Ontario Long Term Care Association (OLTCA), Donna Duncan to discuss long-term care in Ontario.

It’s been a tough six months for seniors living in long-term care, and those working in homes across the province. In our discussion today, we’ll try to understand what went wrong, what when right, and to talk about how we can plan and prepare for the future.

Before we dive into this conversation, I want to introduce our guest. Donna Duncan is the CEO of the largest long-term care association in the country, representing not-for-profit, municipal and private homes in Ontario. I have known Donna for decades and I can tell you first-hand that her passion is public service. She has a storied career in government, in mental health and addictions, and of course, now in the long-term care sector. Donna has served as the interim CEO of the Ontario Caregiver Organization and from 2010 to 2017, served as the president and CEO of the Hincks-Dellcrest Centre, a large children’s mental health treatment, research, and teaching centre. I had the privilege of working with, and learning from Donna at Hincks-Dellcrest. Thank you for joining me today, Donna.

Donna Duncan: Thank you, Patrick. I’m pleased to join you.

Patrick Nelson: So, let’s start by going back to a year ago, or so, when you took on this new job. I ask, sort of jokingly, but also with great interest: is it everything you expected it would be?

Donna Duncan: (Laughs) And more. I don’t think I had any – any of us had any inkling what January and February would bring and certainly what’s transpired over the last few months. I think, certainly when I came on, my mandate from the board was to realign the organization and position it to drive certain sector change. Little did I know that as we worked over the summer months to build out a plan to guide us, that the changes we were starting to propose from the work of our various committees and new task forces would actually have us in a position to inform exponential change in very short order.

Patrick Nelson: No kidding. Maybe when I think back now, there was also a new government just before you were appointed. Putting COVID-19 aside for a minute, where were things going with the new government?

Donna Duncan: You know, we had the new government come in with a commitment to building new long-term care beds, and really a focus on the beds. As the mandate proceeded with the Ford government, they wanted to demonstrate that long-term care was a priority, so in the summer months we saw the emergency of a new stand-alone, separate Ministry of Long-Term Care that was only just finding it’s legs. So, new ADMs coming in December, and actually an additional ADM has just been built out. So, we were going into COVID-19 with a nascent ministry that was evolving in real-time just as we needed stabilization and preparedness as we moved forward. So, there was that disruption as we separated from the Ministry of Health, and it created both – I would say – opportunities, certainly a focus and some clear leadership to represent the sector at the cabinet table, but also some real challenges as the Ministry was organizing its own business.

Patrick Nelson: How has that – it’s hard to avoid getting into the obvious conversation for too long – but when you think about the work that you were doing with government pre-COVID-19, and how that changed as COVID-19 happened, can you speak to that a little bit about maybe how the priorities have changed?

Donna Duncan: You know, that’s an interesting question because the work we were doing with our members – and we engaged with a lot of member activities over the last year leading into the new year – with a capital redevelopment task force, a red-tape task force, as well as an HR emergency task force. And the proposals that we put on the table for our pre-budget submission to inform the budget considerations of the provincial government for the 2020 budget actually held firm, even through the pandemic. The issues we had identified around an HR crisis, the state of our capital, our buildings, those three- and four-bed room that hadn’t renewed since the ‘70s, our financial model, the fact that we were restricted to these very narrow and highly prescribed funding envelops that really weren’t built around the people we needed to serve and didn’t allow us to support the staffing models that we actually need for a far more complex resident population. So, those pieces were foundational, and even in our pre-budget submission, we were very clear: we were facing a perfect storm at the best of times. So, I would say the planning work and the policy work and the data work – we invested a lot into data analysis and mapping – those elements have really supported the advocacy early in the pandemic, including having OLTCA take the lead in driving to get emergency orders in place.

Patrick Nelson: You know what? I’m glad you raised that because there’s been a lot of focus on kind of what went wrong in long-term care. A lot also went right. So, maybe you can broaden for us all the things that you think went well, and that’s probably not a popular topic, but I think it’s important to note.

Donna Duncan: I think it is an important topic, and I think we have to recognize that long-term care does not exist in a vacuum in Ontario. Certainly, leading into this we were quite siloed, even when we were in the Ministry of Heath, we were very siloed, and we were misunderstood. I would argue that things that were good that came out of this include a better understanding of who we serve in long-term care; a better understanding of our challenges; certainly new relationships with the health care system, hospitals, primary care, public health; certainly an understanding of the HR pressures that no one quite grasped before. But notwithstanding the fact that there was a better understanding of our challenges, the fact that the majority of homes had not outbreaks, that 80% of the homes had no losses, and where we experienced tragic, tragic loss, there was an unfortunate perfect storm of a number of different conditions that fed into it. Certainly, we saw communities coming together, wrapping around long-term care. Certainly, even where there were losses in homes, we saw communities stepping up, community colleges stepping up to help, local businesses coming up to the floor to bring food in and support people. We saw leadership in our sector emerge. A number of our larger members partnered together to put investments in to securing PPE – we know there was a PPE shortage when this started. Our members secured PPE, both for themselves, but for smaller operators who maybe didn’t have the wherewithal to do their own procurement because we were left on our own for a very long time before government stepped up. That kind of leadership and initiative is something that we can’t lose. The fact that we can take control of things, I don’t think that’s something that we would have ever been empowered to do before, but circumstances forced that. We also had a number of our members who established a fund, a charitable fund that would support workers in distress, who were having financial difficulties. Those are good things, that’s leadership, and we don’t hear about those enough, and we don’t celebrate those enough.

Patrick Nelson: Yeah, it’s an interesting point, isn’t it? Just the focus on the things that went wrong. But what gets lost in that are the nurses, the PSWs, the administrators, and others that were working and doing anything and everything they could, working extra time, double time, weekends. So, despite what we read and maybe if I outline this, there has been a lot of finger pointing happening more so in as things have softened up a little bit in long-term care. Some unions are running some pretty nasty ads on TV blaming private operators. The NDP at Queen’s Park is blaming the current government for not doing this and not doing that. The Premier, when he answers questions about what went wrong, he seems to be pointing more at the last two decades and systemic problems in long-term care that haven’t been addressed in the past by governments of all stripes. It’s a tough question to answer, I realize, but is there anybody you think that’s getting off easy in the conversation? Is there one thing, or a few things, that you would point at as far as things that went wrong?

Donna Duncan: You know, I think as we look at what went wrong and what the conditions were, so many of them were out of our control, and we’re all looking for a villain in this. What really concerns us is that the villain is COVID-19. It is an invisible, shape-shifting monster that we certainly know more about today than we did in February or March, and it continues to evolve. But in the quest for a more tangible villain, there are those who are looking through their ideological lens, to tar somebody in this. And that’s unfortunate because if you think the Premier referred to this as a battle, we’re at war, then in wartime we should be coming together and finding some common purpose. What was really disturbing, quite honestly, is that there were those who were looking for the opportunity to advance a political agenda when our focus needed to be on how we build up the sector, not tear it down. So, where were our labour partners? We were very clear as an association in our advocacy and in our media work that labour need to be a partner with us to make sure people got back to work. This shouldn’t have been about legal processes. This needed to be about how we work towards solutions, appreciating that what we were seeing coming into Ontario mapped largely against what we had seen coursed throughout Europe, through Italy, Germany, France, and the UK, certainly in the United States. The fact that the beginning of this was so focused on hospitals, decanting hospitals, making sure hospitals had capacity. There were no discussions on what the protocol were going to be for long-term care, notwithstanding the fact that when we were having those discussions, my partners in Europe were telling us that the tragic losses we were seeing in those European countries were because of the prioritization of hospitals at the expense of care homes, at the expense of seniors, and most especially, at the expense of people over the age of 80. And it was very clear early on that they were the most vulnerable to this. We were lucky that we didn’t have social spread and we didn’t need that hospital capacity, but we were not prepared for what happened in long-term care. I think that’s a collective responsibility. This cannot be on the long-term care homes and operators. The government has a responsibility, the hospitals have a responsibility. Our labour partners bear a responsibility. This was our collective duty.

Patrick Nelson: There’s no doubt. My thesis has been, in really simple terms, that public health was a little bit behind in their protocols and directives around the use of PPE in long-term care homes and the system’s capacity to do testing early was way behind. If you look at the data in long-term care, it seems clear to me the homes that were hit first were hit the hardest, and largely those homes were hit before we were doing broad-based testing, and before public health was mandating the use of PPE across homes, and the big miss was asymptomatic transmission. I’m being really simple, but is that a fair assessment?

Donna Duncan: I would say yes. Timing was important. Timing, location, whether you were in a hotspot. If you were early on, we didn’t know about asymptomatic spread. The fact was, early on we had a shortage of PPE. The government was controlling the stock and the supple of personal protective equipment. There was a shortage of swabs. And those shortages, I believe, contributed to the delay in those important protocols. I would also say part of the challenge was the inconsistency of the interpretation of the guidelines and the fact that the guidance was changing regularly, if not daily, and often times at midnight on a Friday night. The communications in this, consistent, clear communication across the province, across LHINs, or health regions, really was problematic for us. Where the association really stepped up, and where we are really grateful to our board and our members, we were having daily calls in many cases or weekly calls, and our board members were serving as partners and resources and offering operational guidance on the ground through this. I would say the root causes from our data analysis was not ownership, it was when was your breakout? What kind of building were you in? And it was all of the collection of the things together. It was the timing, it was the class of the building, whether you had three- or four-bed rooms, what your HR situation was like, whether or not you were in a geographic hotspot. Those were fundamental to this.

Patrick Nelson: Yeah, you’re bang on. What we’ve seen, I think, is that once the right protocols and directives have been in place, and some time as passed, I think what we’ve seen is that largely long-term care is now managing long-term care really, really well.

So, the commission was announced a month ago or so. Have you heard much about what’s to come and what will you be looking for when the commission does their work and puts forward their report?

Donna Duncan: The commission is still organizing its business. We’re looking forward to connecting with them. We do know that they are going to reach out to the association, and we are looking forward to better understanding how they are going to organize their business. We know that their report is due next spring. What we’re going to be looking for, and where we were pleased with in the terms of reference, is that it’s not long-term care in a vacuum. We want to make sure those contextual pieces are considered, including global and national context, including some of the historical elements of our structural and systemic challenges. But also, a recognition that out of 626 homes in the province, there were perhaps about 30 that ended in what they classify as the “red zone”. And in a very small minority, unfortunately, we did see those tragic loses. But the majority of the system held, and that’s really a tribute and testimony to the efforts of the front-line. And as you said, Patrick, everybody stepped up and did whatever it takes, and again, some really tough conditions. Those people, those individuals, those front lines, especially those in the hardest hit homes, that was traumatic. And I think it’s going to be important that we validate those efforts, validate those conditions that fed into this and make sure that as we move along now, that it’s just not about navel gazing about what we’ve been through, because we are at the end of the beginning, we are not at the end of the pandemic. We have a lot of work to do as we move towards the fall, we’re already seeing outbreaks in different urban centres, and we have to make sure we are prepared to meet that head on, and that we don’t fail our residents, and that we don’t fail our families, and we don’t fail our staff. We’re all in this together, and we have to hold the government accountable for making sure that they do what they say. Premier Ford and the Prime Minister both said, “we’re going to do whatever it takes to fix it”. Well, we need to start fixing it in real time. I think that’s our concern about the commission; that it’s a distraction from what we need to be doing today as we move through the fall flu season, and a potential second wave.

Patrick Nelson: Some have said to me recently that long-term care is stuck on the sidelines or hidden away and nobody talks about it, our government doesn’t invest in it up until something terrible happens, and then everybody runs to fund long-term care, and it’s exactly why we’re in the state that we’re in today, and had been for two decades, it’s because there hasn’t been a crisis in long-term care. Is there any truth to that, Donna? That hospitals sort of keep it on the sidelines and focus on hospitals, and now we’re seeing everybody run to the table to say we need to fund long-term care? Is there any truth to that?

Donna Duncan: It’s an interesting observation. Coming out of the mental health sector and coming into long-term care, I feel a lot of parallels where the government sees the system solutions as being too complicated. There’s stigma. We tend to accept things because people don’t want to talk about these issues, so it’s like you’re not on the radar screen, you’re not going to be a ballot question at the polls. So, governments not inclined to focus in that area. We’re concerned that we had an abundance of focus over the last number of months, largely on not pleasant things and on darkness, not a celebration of what went right, not a celebration of our front-line heroes. But certainly, a focus in a way that drove fear about the sector where the fixing it was going to be somebody else’s problem. We need to fix this together. We’re very worried that as government prepares for back-to-school, schools become the focus, and we’re not talking about long-term care.

Patrick Nelson: You raised two more questions. Because I’m mindful of time, briefly the three- and four-bed ward challenge – is it realistic to believe that government’s going to be able to pull out the thousands of beds that would come as a result of mandating only private and semi-private rooms?

Donna Duncan: It’s a difficult decision for government to make. I certainly, you know from working around politics and media, there is a sense of that they were a root cause. Certainly, as we noted, they were a root cause combined with other confluence of conditions. So, it wasn’t uniquely three- and four-bed rooms. There were a lot of homes in the province with three- and four-bed rooms who had no outbreaks. So, what worked there, and how do we make sure we’ve got those conditions? We don’t believe its realistic for the government to open up the rooms without ensuring the other pieces are in place that we need as part of a wave-two response: additional staff, in-house infection prevention and control expertise and specialization, a mechanism whereby we can ensure we have physicians come regularly on-site to provide some other additional clinical support in the homes on a go-forward basis. These pieces are important, but if we reduce the occupancy on a go-forward basis, that’s about 4,500 beds. That’s huge capacity. We know that right now across the province – I know certainly from listening to our members – we do have hospitals and regional health groups really pushing aggressively on the homes to expand their occupancy. And we also recognize that with occupancy comes an additional co-pay that allows for the management of the homes and the operations of the homes. If the government is not going to allow us to fill those beds on a go-forward basis, then there’s going to have to be some financial offsets as well. So, where do you find the space to deal with the alternate level of care patients from hospitals, but also how do we make sure we have a financially viable sector? Especially those smaller homes, where they are largely comprised of the ward rooms.

Patrick Nelson: It’s a challenge no doubt. Maybe as my last question in our last couple minutes here, I know the OLTCA has put forward an impressive plan to government just on how to prepare and how to plan for wave two. Let’s pretend you’ve got the Premier and the Minister of Health and the Minister of Long-Term Care seated in front of you, or they’re listening, what are the two or three things that are more important than the other eight or nine things? – i.e. where should they prioritize their actions in the next month and a half?

Donna Duncan: Our number one issue is staffing. We’ve certainly learned, both from our members on their experiences with their front-line, but also in trying to recruit and support our members in recruiting staff throughout the pandemic through the creation of our ink to LTC job matching platform, we spent a lot of time doing webinars trying to support the attraction of people into this sector. We’ve heard very clearly that it’s not just about money, and notwithstanding, pandemic pay is over now, It’s not just about money. Yes, people want to be compensated, but they want to know that they are safe. They want to know that they are going to be supported and that the environment is going to be safe so that they can provide the care they need to their residents. So, in order to ensure we’ve got the people that we need, we do need those pieces from wave-one, especially around testing and PPE. Profoundly important. And we would prioritize that infection prevention and control expertise be in the home. It’s not enough just for hospitals to provide that support in the homes, we need to own it, especially with visitors and families coming in and the homes being open. The more that we can ensure that we are doing ongoing supervision and training for on-ing and off-ing and appropriate use of PPE, that’s going to be really important for us. We would prioritize some sort of mechanism that would provide an incentive for the physicians to be on site more so that you do have that additional medical support. Not only our staff, traumatized, and frail, and trepidatious about what’s to come in the fall with flu season and a potential second-wave, we know that our residents are really frail too. Frailer because of the fact that they haven’t been as mobile and haven’t had visitors. So, that’s what we would really focus on, and what’s the mechanisms to get more people in as staff? Can we use these new resident support aides and continue with those through the emergency order to provide a pathway to PSWs where we can grow a PSW workforce in the short-term as quickly as possible? But HR really is critical, and if we don’t have people, then we’re not going to be able to care for people.

Patrick Nelson: Yeah, there’s no doubt, and I feel like it’s something that everyone can unite around just about acknowledging the great work that the nurses, the PSWs, the dieticians, and everybody else has been doing in long-term care. And in doing so, expressing how rewarding a career in long-term care can be. On that note, Donna, as we wrap up here, I just want to thank you for your leadership over the last six months in particular. It’s been a trying time and there has been so many things thrown at you and everybody else working in long-term care. So, thank you. And in some ways we’ll look back and say that you were the right leader for the right time. So, we wish you well and we hope you’ll come back and thank you as always for the work you do and for participating in this conversation.

Donna Duncan: Well, thank you Patrick. You’re very generous. It’s great to share this with you, and thank you to you and your team. I know that you really supported the front lines and you were there in those most difficult situations and you’ve been a great partner. So, thank you.

Patrick Nelson: Thanks, Donna. We’ll talk to you again soon.

Donna Duncan: Great. Thank you.