by Stuart Foxman
Dr. Hugh Boyd, long-term care lead for St. Joseph’s Healthcare Hamilton has supported a medical management program that helps to deliver more individualized care to patients in long-term care (LTC) settings, improve clinician engagement and possibly reduce mortality of LTC residents during the pandemic.
Successes around COVID-19 are worth celebrating, especially when you’re dealing with one of the most vulnerable populations: those in long-term care facilities. “I believe this has helped phenomenally, both with person-centred care and health-system stability,” says Dr. Boyd. He’s talking about a medical management program that started in November 2020. It creates a community of practice, connecting the hospital and LTC homes in the area. The program aims to support LTC residents with mild-to-moderate COVID-19 and improve their care.
Twice a week, experienced LTC family physicians and an experienced COVID-19 internal medicine physician host Zoom calls with participants. All LTC physicians and nurse practitioners who work in Hamilton-area homes are invited, but there’s a focus on those working in large outbreaks. The calls are an opportunity to receive education on managing COVID-19 outbreaks effectively and efficiently, ask questions of the experts, troubleshoot difficult scenarios with their local peers and discuss medical services options.
Dr. Boyd, who is also chair of the OMA Section on Long-Term Care/Care of the Elderly, feels the program is easily adaptable to help provide local solutions during the heights of pandemic waves. He says this model promises to deliver more individualized care, improve clinician engagement and possibly reduce mortality.
To Dr. Boyd, ageism and discrimination have coloured the way long-term care residents have been viewed during the pandemic. He describes the cynical attitude held by some. That older Canadians shouldn’t suck up hospital resources. Or, that these people are old and frail and approaching the end of life anyway. So it’s no surprise that they’ve fallen ill. If not from COVID-19, it surely would have been from something else.
Perhaps, he says, ageism has played a part in how long-term care residents are cared for as well. Dr. Boyd is well aware of the derisive slang ”gomer”: get out of my ER. It’s used to reference elderly patients who have chronic conditions and need long-term care facilities, but who instead take up space in acute-care hospitals. On the flip side, sometimes, he says, residents are kept in long-term care when they want and need to be transferred. That’s wrong and dangerous.
Research shows a significantly fewer number of transfers from long-term care to hospital than would have been expected even without the pandemic. With broad do-not-transfer policies, which Dr. Boyd has opposed, the sad truth is that many residents die and/or suffer. Conversely, there are times when long-term care home residents are transferred to hospital when it’s not really warranted. That too can be detrimental.
“Devastating and heartbreaking”—that’s how Dr. Boyd describes the impact of the pandemic on long-term care residents. Dr. Boyd also serves as medical director at St. Joseph’s Villa in Dundas, one of Ontario’s largest long-term care homes. Hamilton’s first COVID-19 death was a nursing home resident: an 80-year-old woman who died last March 24. Then, the city’s Rosslyn Retirement Residence was fully evacuated in May 2020, after an outbreak infected all but two of the 66 residents and 22 staff. Most residents were transferred to hospital. Sixteen died in that outbreak.
With every additional outbreak since in LTC homes and retirement homes, Dr. Boyd kept asking himself: Are we doing enough? Can we do better? In addressing COVID-19, the initial focus in long-term care was on infection prevention and control and staffing. "That’s understandable," says Dr. Boyd. “But very few people were asking what’s the best way to treat COVID-19 once you have it, and how do you provide the best management,” he says.
In the pandemic, and always, Dr. Boyd has advocated for person-centred care in LTC. That means the best possible care for each resident in the most comfortable place of their choosing. The medical management program can help.
The program got off the ground thanks to the leadership of Dr. Tammy Packer, chief, Department of Family Medicine for Hamilton Health Sciences and St. Joseph’s Healthcare Hamilton. She brought Dr. Boyd together with local experts Dr. Zara Khalid and Dr. Doug Oliver.
Here’s how a medical management program can work. It requires a hospital corporation to have an experienced long-term care physician as a support lead (an average of four hours a week), and a designated COVID-19 expert (hospitalist, internal or emergency medicine specialist for two hours a week). They are funded through a COVID-19 non-clinical stipend. The program also needs administrative support, maybe two to four hours a week. In Hamilton, that’s provided by a mix between the hospital and their local family health team. The goal is to reach out to the medical staff of those long-term care homes experiencing COVID-19 outbreaks and extend some of the hospital expertise. Dr. Boyd says that includes sharing evidence-based medicine, the skills of monitoring and treating acutely ill patients, and identifying the resources to do this safely.
With all this, he says the medical management program offers some much-needed clarity for long-term care homes dealing with caseloads. In addition to attending the calls, the lead physician reaches out to long-term care homes in difficulty to provide one-on-one support and encourage all of their medical services staff to attend the twice-weekly support calls. "If you build it, they don’t always come," says Dr. Boyd, so nurturing relationships helps a lot.
The program also relies on mild and moderate COVID-19 order sets developed by Dr. Boyd and Dr. Zahira Khalid, an internal medicine specialist at St. Joseph’s Healthcare. Based on the symptoms, the sets include a series of standardized treatments to consider. It allows you to tick off the boxes, quickly determine the most appropriate treatment, and reduce variability in approaches, says Dr. Boyd. “It’s a quality tool,” he says. The order sets have been very practical for his local long-term care facilities and can always be customized depending on local resources. Dr. Boyd has provided editable versions to other jurisdictions.
“Our approach has been to improve care so there’s less need to transfer,” he says. “We do believe that for mild-to-moderate cases we can provide better care if we treat people in their own home, by people who know them.” Even moving residents from one room to another in a long-term care home, let alone from long-term care home to hospital, increases the chances of delirium. That’s hazardous to health too, notes Dr. Boyd. If staff can provide quality care in LTC, and if residents and their families say they’d rather get that care there, that’s a compelling case. At the same time, the program strives to give clear guidance on when end-of-life care or hospitalization may be warranted.
What does success look like? At St. Joseph’s Villa, Dr. Boyd points to not only the residents who recovered but also to how those who passed away were handled. Whether they received high-quality end-of-life care in their own home or intensive hospital interventions, everything was guided by their goals of care.
Along with the education provided by the medical management program, Dr. Boyd says support is critical. That includes empathizing with the professionals serving long-term care homes and validating their experiences. “That has had an impact,” he says.
There is already a community of practice in Ottawa and there is keen interest in adopting this model in Kitchener-Waterloo and Windsor/Essex. “We can teach anyone how to do this,” says Dr. Boyd. He says doctors who are in the COVID-19 battle are under tremendous stress. Long-term care is one of the flashpoints. But help is available. “Reach out to your colleagues for support, and work with them to make sure your patients can receive the best care,” says Dr. Boyd. “You don’t ever have to be alone in this.”
For more information about what a community of practice can look like for long-term care and COVID-19 are encouraged to contact: Dr. Hugh Boyd, LTC lead for St. Joseph’s Healthcare Hamilton or Dr. Ben Robert, president of Ontario Long-Term Care Clinicians.
Stuart Foxman is a Toronto-based writer.