Could private seniors' residences be the next weak link in the fight against COVID-19?
Better dialogue, rather than paternalistic approach, may help province find allies in older adults
As COVID-19 cases continue to rise in Quebec, several private seniors' residences are grappling with outbreaks, a trend that provincial officials are monitoring closely.
After a relatively stable summer, the number of COVID-19 cases in résidences pour aînés (RPA), or private seniors' residences, has steadily crept upward from just 37 at the beginning of September to 159 on Monday.
Of the 36 residences with reported cases, four — all located in outlying regions — are considered critical, with more than a quarter of the residents confirmed positive.
One RPA in the Quebec city area has more than two dozen cases.
Another in Beauport, which is under close watch, has 30 cases.
"We are very concerned about the RPAs," said Health Minister Christian Dubé last week.
RPAs currently have nearly three times as many reported cases as CHSLDs, where the virus decimated elderly patients during the first wave.
Yesterday, another outbreak was reported at an RPA in Laval. So far, 20 residents are infected but the cases have not yet been added to the latest government statistics.
"We've been working extremely hard over the past three to four months in the CHSLDs," Dubé said, "but the RPAs, for me, that's our next problem if we're not careful."
What is fuelling the increase?
The reason some RPAs are experiencing flare-ups is linked, in part, to how the virus spreads.
"These kinds of facilities, in general, are the perfect place for outbreaks to occur," said Dr. Leighanne Parkes, an infectious disease specialist and microbiologist at Montreal's Jewish General Hospital.
Unlike a CHSLD, which has a more institutional, hospital-like setting and is equipped with a large medical staff, an RPA is more like an apartment building. Residents are typically independent or require minimal help.
Hallways and elevators are shared and people enjoy communal spaces such as a dining room or activity rooms.
"You have a high concentration of very susceptible individuals all in an enclosed space, all interacting at a time where people might not necessarily be symptomatic yet — in a way that's clinically identifiable — but are most infectious," she said.
By the time the virus is detected and people are isolated, the infection has probably spread widely.
Up until last week, only family, friends and staff were required to wear a mask inside RPAs.
Last week, the health minister extended that rule to residents as well.
A patients advocacy group, Les Usagers de la Santé du Québec (LUSQ), is surprised it took so long.
The group's executive director, Pierre Blain, said the uptick in cases could indicate how unprepared RPAs are for a second wave of the virus.
"I think we will have a very difficult situation this fall," said Blain, who worries the province only seems to get involved once a problem is flagged.
Blain suggests that staggering meal times or limiting capacity in common rooms would be a good pre-emptive move.
He also thinks the province should do more to ensure employees don't work at more than one residence.
Blain says he'd like to see regular spot checks to make sure the staff is trained and following infection control and prevention guidelines.
Since mid-April, Quebec's Ministry of Health says teams from the regional health authorities have been visiting RPAs in their territories to ensure they are complying.
The ministry has also offered free training on infection control and prevention to staff at all RPAs.
There is also closer co-operation.
At the end of August, Résidence du Verger, a private retirement home in Saint-Jérôme, had an outbreak. As of last week, 36 people — 26 residents and 10 employees — were infected according to the CISSS des Laurentides.
That RPA, which is owned by Cogir Management Corporation, said as soon as a positive case was identified, the regional health authority came in to test residents and helped isolate sick residents in a red zone.
"Employees are not allowed to go out of that red zone into other sectors of the residence," said Frédéric Soucy, the president of Cogir management.
Outside visits were stopped and the dining rooms and common areas were closed. A doctor also came by daily to monitor the residents' symptoms, Soucy said.
The number of cases has steadily declined and the regional health authority believes the outbreak is under control.
Limiting staff mobility
During the first wave, personnel working in more than one environment contributed to the spread of COVID-19 in CHSLDs and RPAs.
"Certain exceptional situations, such as the risk of a service disruption, may result in employees being called upon to work in more than one environment," said health ministry spokeswoman Marjorie Larouche in an email. "In these situations, very strict rules must be observed. Mobility should be kept to a minimum, and it should be documented."
Cogir, which owns 40 RPAs in Quebec, said it has a registry to monitor where else their staff is working.
"If they work for us two days a week and then they work at a grocery store another two days, we know where they work," said Soucy.
At the start of each shift, employees have a temperature check and answer a questionnaire about their symptoms and who they were in contact with.
To limit the spread of the virus, staff are assigned to specific floors or sections of the building.
"We want to make sure if you work on a care floor, you're going to be designated to that floor and you're not going to work in another portion of that property," said Soucy.
He believes the biggest challenge for the RPAs will be if employees get sick. So far, Cogir's care homes are well-staffed, but if there is an outbreak, understaffing could be an issue.
He also believes the RPAs could be in trouble if the province removes the premium it pays health care workers. So far, Soucy said staff turnover is low, but without that pay bump, it might be another story.
Communication is key
The prospect of having their freedom limited again or being confined to their apartments is likely causing many older adults a lot of stress right now, said Professor Marie Beaulieu, who works in the school of social work at the Université de Sherbrooke.
Beaulieu has worked in the field of aging for more than 30 years and is currently collaborating with several RPAs on a few projects.
She said many seniors resented being treated like children during the first wave of the virus. She believes the province dismissed the capacity of older adults to make decisions for themselves.
"We kind of treated everyone 70 plus, and at one point, it was even 60 plus, as people in danger or people to protect," said Beaulieu.
During the first wave, Beaulieu said her aunt, who lives in an RPA, had advised the front desk she was going out for a medical appointment. But when she got in her car and tried to leave, the garage was locked. None of the residents had been advised beforehand.
If the province plans on crafting a message targeted at seniors, Beaulieu said, it needs to talk to them.
"It's the difference between the carrot and the stick," said Beaulieu.
She said health authorities may find allies in seniors associations or residents committees, who usually have the well-being of the entire building in mind.