Covid-19 and care homes: the myths and realities

To date all the people who have died of Covid-19 in New Zealand have been more than 60 years old, and more than half lived in aged residential care. Care homes account for almost a third of the disease clusters. We have seen that once the virus invades these homes, it spreads like wildfire, not only to other residents but also to caregivers and nurses.

Worldwide, Covid-19 death statistics for older people in care homes are staggering. In Europe, official counts indicate people living in care homes account for 54 percent of all Covid-19 deaths. However, many care home deaths have not been included in official tolls and it is estimated the real toll of Covid-19 deaths may be up to five times higher.

Both overseas and in Aotearoa, Covid-19 has laid bare the negative impact of undervaluing aged residential care and positioning these facilities outside normal healthcare services.

Two district health boards have had to admit residents to hospital from affected care homes due to a lack of staff. For those of us working in the sector, this is not unexpected. Aged care staffing levels have not changed for two decades despite our research indicating residents have become frailer and more unwell. Staff feel stretched even outside a pandemic. This is reflected in feedback we receive in our research about family and whānau experiences of care. “The staff are lovely, but they are so busy” is a frequently heard refrain.

It may surprise some that in New Zealand, almost half all people aged over 65 will require 24-hour care at some point, and that the highest proportion of all deaths occur in residential aged care. Very few of these deaths require hospitals as residents are expertly cared for by aged care staff with advanced palliative care skills. Our recent study showed the end of life experience in New Zealand aged care ranks highly compared to a similar study of six European countries.

Despite this high quality, aged care facilities are often villainised in the media, which adds to the distress of families whose loved ones require this care. As a society, we now fear old age disability more than death itself. But it is the perception of old age frailty, disability and the need for 24-hour care that is our enemy, not residential aged care itself.

That is not to deny the potential to improve resident, family and whānau experience of aged care, particularly at end of life. Care home resourcing is often contested due to the confusion between the profits from property development of independent living retirement villages and the relatively low funding provided for 24-hour full time care provided in care homes.

For the same cost as a hotel room, care homes must provide all the necessities of life including 24-hour nursing care, medical care, food, activities, equipment, transportation, etc. Although resident needs are often similar, the daily rate paid to care homes is between one half to one-fifth that paid to hospitals and hospices. The building of new aged care facilities is now mainly supported through the profits of retirement villages, and privately paid "premium charges" are now common. These additional costs are born by the consumer, creating a two-tiered residential aged care system.

Population trends show with increased longevity comes a longer period of disability and frailty at the end of life. For the vast majority of us, death will not come suddenly, but will follow a period of disability lasting anywhere from months to years. We must begin to acknowledge that admission to aged care is not a failure, but a necessary component of the overall continuum of healthcare in a society that values all people.

It is time that we stop the worn-out view of aged care as a tragedy and instead value the essential care it provides for the most frail in our population. Often the knee-jerk response to improving quality in aged care is yet another audit from outside agencies. Instead, what is needed is a realistic review of the current population's 24-hour care requirements. This must be done in collaboration with aged care providers to actually supply the resources necessary for specialised frailty care that is needed not just during times of extreme crisis like the Covid-19 pandemic but always.

This would likely result in improved staffing models, better payment structures and more recognition that aged care homes are not only where people die, but where they live during the last stages of their long lives.