A Tale of Two Reports: BC’s COVID response in long-term care

What are the similarities and differences of the Ernst & Young and Howegroup reports?

(Howegroup) Review of The Response To COVID-19 In Seniors Care and Living
(Ernst & Young) BC Ministry of Health Long-term care COVID-19 response review

During the summer months of 2020, the SARS-CoV-2 pandemic loosened its grip ever so slightly on British Columbia’s seniors care homes. As the early coronavirus outbreaks concluded thanks to warmer conditions and the tireless efforts of care home staff, time was provided for reflection and review of what had happened during the presumed “first wave” of the pandemic, and to set a strong foundation in preparation for what was coming next.

It was understood that the experience of the 1918 Spanish Flu pandemic showed there could be three distinct waves, with the second being the deadliest. It made sense therefore to prepare for what was likely to – and ultimately did – arrive in the fall.

BCCPA’s board of directors gave direction to the Association in the spring to prepare a report on the events surrounding seniors care leading up to and during the first months of the pandemic. Data and important dates were meticulously archived in preparation for this. Some of that research is included in our website’s public timeline.

In creating its own review of the COVID response, BCCPA took additional steps to allay concerns around bias in the report commissioned by the association by hiring Howegroup as independent consultants, and having the report vetted by a six-member academic panel chaired by Dr. Carole Estabrooks (Faculty of Nursing, University of Alberta).

Both the Ernst and Young (EY) released this week by the Ministry of Health, and the Howegroup reports were developed on the same timelines — beginning in July, with most of the interviews taking place in August. The E&Y report was submitted to the Ministry of Health on October 22, just 2 days prior to the B.C. election day. The Howegroup report was submitted soon after (November 10) after responding to comments from the Estabrooks panel.

What follows are points on where the reports agree and where they differ, starting with some quick facts.

Quick Facts

Howegroup Ernst & Young
Third party review Six-member academic panel review led by Dr. Carole Estabrooks EY did not independently verify the completeness or accuracy of the information and documents provided to us as part of this review.
Start date July 2020 July 2020
Completion date November 9, 2020 October 22, 2020
Release date November 19, 2020 January 25, 2021
Recommendations list Ten “priority” and 24 recommendations overall. Sixteen short term and five long term recommendations (21 total)
Approach To provide the BCCPA Board of Directors with a report of the impact of COVID-19 in the seniors care and living sector along with actionable recommendations for the Ministry of Health (inclusive of long-term care, assisted living, independent living and home health). This review focuses on understanding the impact of BC’s policy and operational response to COVID-19 in LTC and AL facilities and developing recommendations for how the response can be improved to continue to mitigate COVID-19 risks moving into the fall and winter.
B.C. Pandemic timeline Posted at bccare.ca In report
Method Howegroup conducted a brief survey and facilitated a participatory exercise with BCCPA Board members to define the engagement purpose and scope in March 2020. An active Advisory Committee comprised of BCCPA senior leadership and Board members provided ongoing oversight and direction into this engagement. A mixed methods engagement strategy was utilized, inclusive of a member survey (n=72 of a possible 134 long-term care and/or assisted living providers), interviews (n=25), roundtables (n=13 independent living and n=13 home health providers) and an online member submissions portal limited to input on draft recommendations submitted to the Ministry of Health (18 written submissions received). Conducted one-on-one or small group interviews with more than 40 stakeholders from the Ministry of Health, health authorities, BC Centre for Disease Control (CDC), seniors’ associations, care home operators, providers and front-line staff.
– Reviewed Ministry of Health policy and operational documents related to COVID-19 outbreaks and response
– Considered data related to BC’s outbreak rate, mortality rate, and demographics from BCCDC, Government of Canada, and the World Health Organization

 

Contrasting EY & Howegroup reports

General comment. EY and Howegroup reports both provide an overview of some of early challenges (i.e. inconsistent communications, securing PPE, HHR,  etc.) and a snapshot of some of the early initiatives taken (i.e. single site orders, visitation restrictions, interfacility transfer guidelines, etc.). However, the delay in the government’s report can be seen as a lost opportunity to drive important changes in preparation for the second wave of the pandemic.

Sector-wide gaps in IPAC/PPE guidelines. Each report points out the gaps in infection protection and control (IPAC) practices and emergency preparedness related to COVID-19, and inconsistent application of clinical standards and use of PPE across all health authority regions. Operators were at times subject to confusing messages surrounding requirements for use of PPE, such as gloves, gowns and masks.

Inconsistent or poorly communicated policies. Both reports speak to the varied interpretations and implementation of provincial health orders and policies. In some cases, orders would be rescinded sometimes just hours after being implemented or issued during evenings and weekends, creating distress among staff. This issue forms the basis of a recommendation on making sure that all health authorities align their messaging.

Workforce policies. Both reports agree that early implementation of workforce-related policies – such as the single site order (SSO) and wage leveling policy had a significant and positive impact on reducing the overall spread of infection. While the SSO was something BCCPA advocated for early, it is understood that it exacerbated system-wide labour shortages.

Government owned/operated vs private/affiliate sites. The government’s EY report notes variations in how care homes were treated by health authorities depended on whether they were HA owned and operated or non-government sites. Health authority sites were able to more easily procure PPE or gain access to IPAC education and training than their non-government counterparts. There are multiple examples where affiliates are “left to their own devices” in securing PPE, whereas acute hospitals where prioritized for these products. In some examples, affiliate sites were also vulnerable to the HA’s recruitment efforts and incentive bonuses, and lost front-line and supervisory staff during this critical period. The Howegroup report did not look at the experience of health authority operated sites, and therefore did not provide that contrast.

PPE availability. The reports agree that a lack of centralized supply coordination resulted in challenges with distributing and directing PPE supplies to where they were needed in a timely manner. And despite funding for HAs to create PPE stockpiles for use during a pandemic, much of the inventory was badly depleted at the onset of COVID-19.

Family and visitor restrictions. Both reports conclude that restricting visitors and resident outings were seen as an effective early measure in reducing the spread of infection. However, the EY report does not adequately deal with some of the isolation and other mental health issues faced by seniors and their families, nor does it contrast how these policies were applied in other jurisdictions. On June 18, BCCPA issued a call to loosen restrictions on visitors.

On-site supports. Each report notes that on-site support and the physical presence of HA leaders at LTC facilities under outbreak was a crucial and effective element of responding to the spread of infection. However, the level of support provided varied across health authorities, with Vancouver Coastal Health seen as providing the best LTC rapid response overall.

Multi-bed wards. While the EY report highlights some of the physical design characteristics of LTC and AL facilities likely contributed to the vulnerability of these settings to the spread of infection, it does not adequately address use of multi-bed rooms.

COVID-19 special units. The EY report raises the issue how to isolate COVID-19 positive residents from the general population, but does not follow the Howegroup report recommendation to consider separate isolation units outside of the care home. Specific protocols outlined in health authority ethical decision frameworks were sometimes not followed.

Single site order limitations. While each report cites the single site order as an important tool for reducing the spread of infection, only the Howegroup report mentions that the SSO did not limit LTC staff from also working in acute or other occupational settings.

Wage levelling. Though wage levelling was seen as an important part of the province’s COVID response in LTC and AL, several operators were left covering the upfront cost of additional wages for employees. The uncertainty over when the funding would be in place to cover wage levelling led to frustrations in the workplace, and some financial distress on the part of the operators. Pandemic related costs remains a major issue sector-wide.

EY report gaps

There are also some key areas discussed in the Howegroup report that are given passing mention or no mention at all, including:

Testing. The Howegroup report requests that the Provincial Health Officer establishes rapid testing alongside screening protocols for residents and staff in long-term care, assisted living, and independent living. This measure would support robust protocols for safe and frequent social contact between residents and family members, working with SafeCare BC to support these efforts.

Designated COVID-19 units. Provide the option in cooperation with families to exercise options for separate designated COVID-19 units to protect vulnerable populations.

Decommissioning sites with multi-bed wards. The EY report provides no recommended approach for working with operators to upgrade or decommission care homes and replace with newly created bed stock. Since the report recommendations, the provincial government has announced a plan to renew care home infrastructure operated by health authorities.

Social and/or spiritual supports. The Howegroup report recommends using professional positions for social and spiritual supports in the care setting. These supports are intended for those dealing with emotional toll of the pandemic.

In conclusion

Both the Howegroup and EY reports provide an excellent snapshot of the period leading up to the second wave, and each provides dozens of solid recommendations. Some of these recommendations have already been acted upon, while the majority have not. We applaud the work done by the authors of each report and thank all those who shared their time and perspectives for them.

It is now imperative that we consider all the recommendations put forward in the Howegroup and EY reports, and work with the Ministry of Health and health authorities to make improvements to our continuing care sector for the long term.

Read the recommendations:

BCCPA Pandemic Next Wave report page

Howegroup report (executive summary and recommendations)

EY report