In the stay-at-home era, why have we so sorely neglected home care?

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There’s no place like home.

That truism has taken on a whole new meaning during the COVID-19 pandemic, owing to quarantines, isolation, lockdowns, shelter-in-place orders and other restrictions on movement.

But in health care, the focus has been placed squarely on institutions.

Out of fear of a mass influx of coronavirus patients that could overwhelm hospitals, beds were emptied in record time. Virtual care was embraced with the zeal of converts. Elective surgeries were cancelled. Patients listed as needing an “alternate level of care” – meaning they were discharged, but also classified as too “high-need” to go home – occupied as many as one-third of hospital beds and were shipped off to long-term care and nursing homes.

Virtually no one was discharged to the safety of their own home. And those who were already getting home-care services saw these services cut back drastically.

A survey of three large Canadian home-care providers – SE Health, Bayshore and VON Canada – found that in the weeks after lockdown, home-nursing care dropped 22 per cent; personal support workers’ services were reduced by 31 per cent; and home-based therapies such as physiotherapy and occupational therapy plummeted by 65 per cent for those big three providers.

In short, the home-care sector, already underfunded and undervalued, was decimated.

The idea – to free up resources for a crush of hospitalized patients – was well-intentioned but, in retrospect, deadly.

More than 80 per cent of COVID-19 deaths in Canada have been in institutional care. In Ontario alone, there have been 2,049 deaths in congregate settings, 1,774 of them in long-term care facilities.

One in every 50 residents of long-term care in Ontario has died of COVID-19.

In addition, thousands of workers in these homes have been infected with the novel coronavirus.

Meanwhile, you can count the number of home-care workers and clients who have been infected on your fingers and toes – and not just because hundreds of thousands of visits were cancelled.

In institutional settings, COVID-19 proved deadly because it spread among highly vulnerable patients who were sharing rooms, bathrooms and support staff.

Home care is one-on-one care. It is true that home-care workers see many clients, but rarely as many as those toiling in institutions.

In individual home visits, the virus doesn’t have the opportunity to take root. Workers take care of one person at a time, so there is little chance of spread.

There have been high rates of COVID-19 deaths in institutional care in many countries, but Canada is among the worst, if not the worst in the world.

We now know the reasons all too well: Outdated infrastructure, lack of staffing, poor pay and benefits and disorganization, among others.

Yet, as bad as conditions can be for personal-support workers and nurses in institutions, they are often worse in the community. For home care, workers earn $3 to $5 an hour less than they would in institutions, and it’s piecemeal work, so they are under pressure to work quickly.

When it came to doling out personal protective equipment, home-care workers were the last in line, which is symbolic of the way the sector is neglected.

Canada has one of the highest rates of institutional care and one of the lowest rates of home care among developing countries, so our high death rate is not a surprise. A flawed system again delivered poor results.

In Canada, long-term care has become synonymous with being shipped off to an institution. While facilities are essential for some, they should be a last resort, not the default setting.

The carnage in congregate care, if nothing else, obliges us to rethink elder care fundamentally.

A good starting point is prioritizing home care.

Ontario, for example, has a $64-billion annual health care budget, of which $3-billion goes to home care and $4.3-billion to long-term care. (Individuals supplement those costs, often paying thousands of dollars out of pocket.) There are a little less than 100,000 residents in long-term care, and more than 700,000 who get home-care services.

This pandemic has shone a light on how we have brutally failed our elders.

Who, going forward, will not think twice about placing a loved one in long-term care? Who will not ask: How can we keep Mom or Dad safe at home?

The right care at the right place and at the right time needs to be the mantra of a patient- and family-centred care system.

To fulfill that mission, one of our priorities has to be the allowance of people to age in place, to give them the choice of living at home and dying at home, with proper supports.

As Shirlee Sharkey, chief executive of SE Health, says, "Two of the key lessons of the pandemic are: Home is a safe place to be. And home is where people want to be.”

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