Ontario has so far avoided the “Italy scenario” with COVID-19, which would have seen the sick and dying overwhelm the province’s hospitals, leaving doctors with more patients than there were ventilators to save them. But there remains cause for concern: in the province’s long-term-care homes, elderly people with serious pre-existing conditions have made up a disproportionate share of the disease’s death toll. As of Thursday, 163 of the province’s 423 deaths — or nearly 40 per cent — had been in LTC homes.
A researcher from the University of Waterloo is warning the government, however, that another population of elderly people is at risk from COVID-19 and could swamp the province’s hospitals if action isn’t taken: home-care patients.
“If COVID-19 infects the home-care population, they alone could overwhelm the hospital emergency departments and inpatient settings,” says John Hirdes, professor of health studies and gerontology at Waterloo. “We’ve finally become aware of the problem in nursing homes, but we don’t quite recognize what’s happening in home care, because they’re not easily identifiable as a population.”
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Hirdes and his team estimate that, even in a scenario in which only 5 per cent of the home-care population were infected, more than 11,000 people could end up needing admission to hospital. As of Thursday, only 1,137 people had been hospitalized in Ontario since the beginning of the outbreak.
There are two reasons the home-care population could put the province’s hard-won hospital capacity at risk. The first is that it’s simply larger than the LTC population, so even a smaller rate of infection could translate into more people in beds. In Ontario, Hirdes is most concerned about the 144,000 home-care patients who would, if they didn’t have a family caregiver, most likely be in LTC facilities, which are home to 77,000 people.
Queen’s Park has, in fact, made a point of promoting home care for patients who could be released from hospitals or LTC homes, because it’s cheaper and often safer to keep people out of hospitals.
While home-care patients are doing exactly what everyone else is being told to do — stay home — Hirdes says that the nature of home care poses some serious risks to the patients, even if they’re safer overall than people in LTC homes.
“The challenge is that one home-care staffer may see six to 10 clients that day. So the chance of a home-care staff member inadvertently exposing a home-care client to risk is pretty substantial, and there’s no way of getting around that,” says Hirde. “You can’t assign one staff to work with one client — we just don’t have the volume of staff.” The problem mirrors the one in the LTC system, where staff have moved from home to home out of economic necessity (they’ll continue to be allowed to until next week, when a provincial order comes into effect).
The difference, however, is that when a person gets sick in an LTC home, they’ve generally been cared for there and, in 163 cases, have died there.
“In home care, there’s nowhere for this person to go except a hospital,” says Hirdes. “You can’t discharge them to a nursing home, because they’ve got COVID-19.”
What the government doesn’t have is solid projections about the possible death toll in long-term care and home care. Using pneumonia as a proxy for COVID-19, Hirdes says, one can estimate that the patients most at risk — people over the age of 80 with three or more pre-existing conditions — could see death rates as high as 30 per cent in LTC homes and that a similar population in home-care would see a rate of below 15 per cent. Except, of course, that pneumonia isn’t COVID-19.
“Using pneumonia last year as a modelling variable — historically, it doubled the mortality rate in home care and nursing homes,” Hirdes says. “If people in those settings get COVID-19, I expect it would be worse than pneumonia has been in the past.”
He is also concerned about elderly people who aren’t currently either receiving home care or living in LTC homes. If they aren’t getting regular medical attention, he says, they could get sick without anyone knowing.
“There are a lot of people who don’t really have any real assessment systems to monitor their needs,” says Hirdes, who’s also the senior Canadian fellow and a board member on interRAI, a network of researchers in 35 countries that develops clinical-assessment tools for doctors. He and his team have created a questionnaire that can be administered by someone who isn’t a medical professional — they don’t want to divert doctors or nurses right now — that can help determine whether a patient needs more attention from the health-care sector.
“My nightmare scenario is someone who maybe has mild COVID-19 symptoms and is told they shouldn’t come to the emergency room, but they’re frail — maybe they live alone, and they’ve got multiple underlying health issues,” says Hirdes. “Those are the people at serious risk of dying, because they fall through the cracks.”