Allan Grill is the Chief of the Department of Family Medicine at Markham Stouffville Hospital and an Associate Professor at the University of Toronto.
Since my first day as a family physician, I’ve looked after frail seniors living in long-term care (LTC) settings. I remain fascinated by the complex nature of their multiple medical conditions and the resiliency that accompanies them. I’m a strong supporter of interdisciplinary team-based care and the multitude of skills required to meet the daily care needs of this population. I’ve cared for many Canadian veterans from the Second World War and Korean War and have been touched by the personal stories they have shared.
It therefore saddened me greatly to hear about the devastating impact that the COVID-19 pandemic has inflicted on seniors’ homes. Over 80% of all fatalities in Canada have been linked to these settings and, in Ontario alone, there have been about 250 institutional outbreaks. Challenges associated with physical distancing, difficulty isolating symptomatic residents with cognitive impairment, and staff working at multiple facilities have all been contributing factors.
Surprisingly, most of the discussions pertaining to this issue have focused on future long-term strategies to correct systemic problems highlighted by these outbreaks rather than immediate interventions. Building larger facilities to avoid overcrowding, ensuring adequate staffing and investing in public health infrastructure are all great ideas, but will take years to implement. It also seems that the voice of family medicine, the specialty that provides the majority of medical care inside these facilities, has not been at the forefront of these conversations. I’ve read commentaries from geriatric consultants, infectious disease specialists, palliative care physicians, nurses, and even CMAJ‘s editors, but very few stories about contributions from my primary care physician colleagues who have been on the front lines. So, I thought it was time to share my own.
I am the Chief of the Department of Family Medicine at my hospital and was assigned the task of developing a LTC strategy towards the end of March, when one of our local nursing homes declared a COVID-19 outbreak. The family physicians on site reached out seeking additional support to keep their patients and staff safe. In my leadership role, I’m aware of the importance of taking time to listen. Anticipating similar scenarios in other facilities, I invited the family physicians working in LTC and retirement homes in our catchment area (approximately 20 in total) to attend a series of weekly virtual meetings. During these discussions, I leaned on these colleagues for their expertise and guidance to help identify gaps and suggest ways to optimize care during the pandemic.
We agreed that the main concerns were how to continue to provide exceptional care to older adults who decide to receive it in their home and the impact COVID-19 outbreaks in LTC could have on our hospital’s surge capacity. Lessons from other countries warned us about the poor prognosis for frail elderly patients who get COVID-19, regardless of whether they were admitted to hospital or not. My family medicine colleagues requested resources to help with advance care planning and goals of care discussions, along with real-time virtual access to specialist consultations for more complex medical issues. This support could help with families that wanted a second opinion regarding the pros and cons of hospital care, as well as guidance around end-of-life care. More frequent access to blood tests (often only available weekly) and diagnostic imaging to prevent unnecessary trips to hospital, along with mobile home care services to start intravenous hydration or insert a urinary catheter, were also identified as urgent needs.
My hospital got behind this. We set up a 24/7 virtual care consultation service involving geriatrics and internal medicine modeled after the LTC plus program from Women’s College Hospital in Toronto. The emergency medicine department devised a process whereby, after a discussion between the LTC family doctor and ER physician, residents of care homes could access imaging studies at the hospital without having to be formally examined in the ER. This would help minimize the patient’s time spent at the hospital and reduce traffic in the waiting room. A mobile team of nurses and nurse practitioners was created to visit these homes, assisting with SARS-CoV-2 testing and infection prevention & control education. The latter helped support local public health teams who were also short-staffed. I joined a task force that began meeting daily with regional stakeholders to identify other unmet needs (e.g. access to PPE, staffing shortages). Communication and accountability became the focus of these initiatives so that no LTC home would be left behind.
Family physicians working outside of LTC stepped up too. A group was recruited to be on-call for any home that did not have regular access to doctors providing house calls (e.g. private retirement homes). The community palliative care team made themselves available for in-person end-of-life care assessments, and created a document on symptom management and psychological support for patients and families. Articles and videos on initiating goals of care discussions, and resources for staff to assist with stress and burnout were compiled and shared. Dr. Jane Philpott, former Chief of family medicine at our hospital, volunteered to help manage an outbreak at Participation House, a facility that supports adults with intellectual and developmental disabilities. She highlighted the need to expand our efforts beyond care of the elderly to include all congregate settings, and we have since included them in our outreach efforts.
I’m proud of these early accomplishments. I also feel fortunate that our patients have been able to receive care by in large in their homes from their own family physician and care providers. Families have expressed their appreciation for this continuity and familiarity as well. Our success is also evidenced by the limited number of admissions to hospital from LTC and other congregate settings related to COVID-19 in our region. My family physician peers have told me that our efforts have “built goodwill”, and “made us feel empowered and better equipped.” The goal of this collaborative effort is to continue building an integrated community of support around these facilities as the pandemic quietens down, and maintain a dedicated leadership team that identifies problems early and finds innovative solutions. We’re well on our way.