Long-term Care Home Residents Research Articles

The Impact of the COVID-19 Pandemic on Long-Term Care in Canada.

The COVID-19 pandemic has disproportionately affected Canada's long-term care (LTC) sector, with residents of LTC and retirement homes accounting for 67% of all COVID-19-related deaths as of February 15, 2021. This study investigated the impact of the COVID-19 pandemic on LTC residents across Canada during the first six months of the pandemic, including how care changed for residents, using data from the Canadian Institute for Health Information's LTC and acute care databases. The results suggest that LTC residents received less medical care, with fewer physician visits and hospital transfers compared with the same period in 2019. They also had less contact with family/friends compared with the same period in 2019, which was associated with higher levels of depression. In provinces where it could be measured, the number of LTC resident deaths from all causes was higher than pre-pandemic years during the peak of the first wave, even in jurisdictions with few COVID-19-related deaths in LTC.

546 - Attachment, loneliness, and depression among residents in long-term care (LTC) homes

Background:Little is known regarding attachment styles among residents in long-term care homes and the relationship with depression and lonelinessResearch Objective:The study evaluated the distribution of attachment among residents in long-term care (LTC) homes and identified their association with depression and loneliness.Method:This study involved 132 residents in LTC homes in Thailand. All of them were cognitively intact based on Mini-Cog. The Thai version of the Experiences of Close Relationships-Revised questionnaire (ECR-R-18), the Relationships Questionnaire (RQ) were used to assess attachment. The Thai version of Geriatric Depression Scale (GDS-6) and the 6-item Revised version of The University of California Los Angeles Loneliness Scale (RULS-6) were completed.Preliminary results of the ongoing study:Participants included 85 females (64.4%) with mean age 74.89 (SD 7.89) years. The mean number of years of education was 6.81(SD 4.46) years. Most of the attachment styles were insecure (60.7%). The distribution of attachment style was 39.4% for secure, 15.2% for fearful, 16.7% for preoccupied, and 28.8% for dismissing. The mean score of attachment- anxiety was 3.58 and of attachment-avoidance was 3.61. Mean GDS score was 1.17 (SD 1.58), while depression based on the GDS cut-off was found in 31.1% of the residents. Mean RULS score was 2.36 (SD 0.75). Factors associated with Depression includes male (c2= 4.50, p <.05), anxious attachment (t = 3.51, p = 0.001) and loneliness (t = 4.90, p <0.001). Anxious attachment was associated with loneliness (p <0.001) and depression score (p <0.001), while avoidant attachment was not.Conclusion:The majority attachment style among residents in LTC homes is insecure attachment, with dismissing style the most prevalent. Attachment with high anxiety i.e., preoccupied, and fearful was associated with loneliness and depression.

208 - Person-centred infection prevention and control during a pandemic: The Dementia Isolation Toolkit

Objectives:People working in long-term care homes (LTCH) face ethical dilemmas about how to minimize the risk of spread of COVID-19, while also minimizing psychological hardship and other harms of infection control measures on residents. The Dementia Isolation Toolkit (www.dementiaisolationtoolkit.com; DIT) was developed to address the gap in ethical guidance for LTCH on how to safely and effectively isolate people with dementia while supporting the personhood and well-being of residents. In this presentation, we will present the DIT and report on the results of a survey of LTCH staff in Ontario, Canada on their experiences isolating residents in LTCH and the use of the DIT in supporting person-centred isolation care.Methods:A link to an online survey was distributed to LTCH staff through provincial organizations and agencies as well as through social media and the DIT website. Inclusion criteria were LTCH staff working on-site at a LTCH since March 1, 2020, who had direct or indirect experience with the isolation/quarantine of LTCH residents. Results were summarized descriptively.Results:A broad sample of LTCH staff (n=207) participated in the survey, most of whom had experienced an outbreak in their LTCH. Dementia (96%) was the most important barrier to implementation of infection control measures in LTCH, followed by staff distress about the effects of isolation on residents (61%). Important facilitators for isolation included delivery of 1:1 activities in the resident’s room (81%) and designating essential caregivers to provide support (67%), while inadequate staffing levels were reported as a barrier (55%). 65% of respondents indicated some familiarity with the DIT, and of those who had used the toolkit, 62% found it helpful in supporting isolation care, particularly in developing care plans and making and communicating decisions. Of those who had used the DIT, 48% found it fairly or very helpful at reducing their level of distress.Conclusions:Isolation as an infection control and prevention (ICP) measure in LTCH environments can be harmful to residents and create moral distress in staff. ICP guidance and support of LTCH needs to address how to minimize these harms by providing dementia-specific guidance such as in the DIT.

There Is No Place Like Home … But Things Could Be Better.

Increasing attention is being placed on the role of the built environment in promoting and sustaining health in long-term care home settings. Work that reconsiders the physical and work designs of the long-term care sector in the future is expected. In light of that, we urge full and reflective consideration of the tensions and complexities that have been brought to light through the pandemic and attending to what is known and knowable about the influences of the built environment on long-term care home residents and staff who provide their care.

The promise of transformed long-term care homes: Evidence from the pandemic

A combination of factors during the SARS-CoV-2 pandemic led to a disproportionately high mortality rate among residents of long-term care homes in Canada and around the globe. Retrospectively, some of these factors could have been avoided or minimized. Many infection control approaches recommended by public health experts and regulators, while well intended to keep people safe from disease exposure, threatened other vital aspects of health and well-being. Furthermore, focusing narrowly on infection control practices does not address long-standing operational and infrastructural factors that contributed significantly to the pandemic toll. In this article, we review traditional (ie. institutional) long-term care practices that were associated with increased risk during the pandemic and highlight one transformational model (the Green House Project) that worked well to protect the lives and livelihood of people within congregate care settings. Drawing on this evidence, we identify specific strategies for necessary and overdue improvements in long-term care homes.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis.

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. Systematic review, without meta-analysis, with vote counting based on direction of effect. Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p<.001), assessment and management services (p<.0001) and non-training initiatives involving medical staff (p<.0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p<.001), but the high number of weak-rated studies undermined confidence in this result. This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

COVID‐19 and Ontario's Long‐Term Care Homes

AbstractOntario long‐term care (LTC) home residents have experienced disproportionately high morbidity and mortality, both from COVID‐19 and from the conditions associated with the COVID‐19 pandemic. As of July 10, 2021, a total of 3,975 LTC home residents have died of COVID‐19, totaling 43.0% of all 9,245 COVID‐19 deaths in Ontario.The most important risk factors for whether a LTC home will experience an outbreak is the daily incidence of SARS‐CoV‐2 infections in the communities surrounding the home and the occurrence of staff infections. The most important risk factors for the magnitude of an outbreak and the number of resulting resident deaths are older design, chain ownership, and crowding.Many Ontario LTC home residents have experienced severe and potentially irreversible physical, cognitive, psychological, and functional declines as a result of precautionary public health interventions imposed on homes, such as limiting access to general visitors and essential caregivers, resident absences, and group activities. There has also been an increase in the prescribing of psychoactive drugs to Ontario LTC residents.The accumulating evidence on COVID‐19 in Ontario's LTC homes has been leveraged in several ways to support public health interventions and policy during the pandemic. Several further measures could be effective in preventing COVID‐19 outbreaks, hospitalizations, and deaths in Ontario's LTC homes. This includes improving staffing, minimizing LTC worker infection, decrowding LTC homes, enhanced infection prevention and control (IPAC) measures, a more balanced and nuanced approach to public health measures, and additional strategies to promote COVID‐19 vaccine acceptance amongst residents and staff.

Models of provider care in long-term care: A rapid scoping review.

IntroductionOne of the current challenges in long-term care homes (LTCH) is to identify the optimal model of care, which may include specialty physicians, nursing staff, person support workers, among others. There is currently no consensus on the complement or scope of care delivered by these providers, nor is there a repository of studies that evaluate the various models of care. We conducted a rapid scoping review to identify and map what care provider models and interventions in LTCH have been evaluated to improve quality of life, quality of care, and health outcomes of residents.MethodsWe conducted this review over 10-weeks of English language, peer-reviewed studies published from 2010 onward. Search strategies for databases (e.g., MEDLINE) were run on July 9, 2020. Studies that evaluated models of provider care (e.g., direct patient care), or interventions delivered to facility, staff, and residents of LTCH were included. Study selection was performed independently, in duplicate. Mapping was performed by two reviewers, and data were extracted by one reviewer, with partial verification by a second reviewer.ResultsA total of 7,574 citations were screened based on the title/abstract, 836 were reviewed at full text, and 366 studies were included. Studies were classified according to two main categories: healthcare service delivery (n = 92) and implementation strategies (n = 274). The condition/ focus of the intervention was used to further classify the interventions into subcategories. The complex nature of the interventions may have led to a study being classified in more than one category/subcategory.ConclusionMany healthcare service interventions have been evaluated in the literature in the last decade. Well represented interventions (e.g., dementia care, exercise/mobility, optimal/appropriate medication) may present opportunities for future systematic reviews. Areas with less research (e.g., hearing care, vision care, foot care) have the potential to have an impact on balance, falls, subsequent acute care hospitalization.

Beyond longevity: healthy longevity

Beyond longevity: healthy longevity

Complexity of Nurse Practitioners' Role in Facilitating a Dignified Death for Long-Term Care Home Residents during the COVID-19 Pandemic.

Due to the interplay of multiple complex and interrelated factors, long-term care (LTC) home residents are increasingly vulnerable to sustaining poor outcomes in crisis situations such as the COVID-19 pandemic. While death is considered an unavoidable end for LTC home residents, the importance of facilitating a good death is one of the primary goals of palliative and end-of-life care. Nurse practitioners (NPs) are well-situated to optimize the palliative and end-of-life care needs of LTC home residents. This study explores the role of NPs in facilitating a dignified death for LTC home residents while also facing increased pressures related to the COVID-19 pandemic. The current exploratory qualitative study employed a phenomenological approach. A purposive sample of 14 NPs working in LTC homes was recruited. Data were generated using semi-structured interviews and examined using thematic analysis. Three categories were derived: (a) advance care planning and goals of care discussions; (b) pain and symptom management at the end-of-life; and (c) care after death. The findings suggest that further implementation of the NP role in LTC homes in collaboration with LTC home team and external partners will promote a good death and optimize the experiences of residents and their care partners during the end-of-life journey.

Cost-effectiveness of a Province-wide Quality Improvement Initiative for Reducing Potentially Inappropriate Use of Antipsychotics in Long-Term Care in British Columbia, Canada.

BackgroundPotentially inappropriate use of antipsychotics (PIUA) raises serious concerns about safety, quality, and cost of care for residents in long-term care (LTC).ObjectiveThis study aimed to estimate the cost-effectiveness of the Call for Less Antipsychotics in Long-Term Care (Clear) initiative compared with the status quo (pre-Clear, baseline).MethodsA model-based cost-utility analysis, from a public-payer perspective in British Columbia, was conducted using secondary data of residents in LTC homes from 2013 to 2019. Residents’ health resource utilization and quality-adjusted life-year (QALY) measures were extracted from multiple administrative databases. Six Markov states were modelled for post-antipsychotic progression representing PIUA, appropriate use of antipsychotic, complete withdrawal, and death. The primary outcome was the incremental cost per QALY gained.ResultsA cohort of 35,669 residents was included in the primary analysis. The Clear initiative, over 10 years, was estimated to have an incremental cost-effectiveness ratio (ICER) of CA$26,055 (2020 Canadian dollars) per QALY gained at an incremental cost of CA$5211 per resident and a QALY gain of 0.20. In the subgroup analyses, our findings were even more favourable for Clear wave 2 (ICER of CA$24,447 per QALY gained) and Clear wave 3 (ICER of CA$25,933 per QALY gained). At a willingness-to-pay of CA$50,000 per QALY gained, the probabilities of Clear waves 2 and 3 were 82% cost-effective.ConclusionThis study demonstrated incremental costs and yielded favourable ICERs for Clear compared with the baseline. More research is needed to understand the level of support for individual care homes to sustain the Clear initiative in the long run.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-021-00267-6.

Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.

Staffing crisis: Addressing the high turnover rate of personal support workers in Ontario’s long-term care sector

Personal support workers (PSWs) serve a valuable role within the health system, providing up to 80% of direct care to residents and clients in the home and community care (HCC) and long-term care (LTC) sectors. According to a report by the Ministry of Long-Term Care, as of 2018, 50 000 PSWs were employed within LTC facilities in Ontario, accounting for the majority of the workforce within this sector. The original purpose of the PSW role was to support residents with activities of daily living such as dressing, toileting, and bathing. However, in an effort to minimize healthcare costs and keep up with the rapidly aging population, there has been a recent shift towards implementing policies that support the idea of aging at home. The criteria for admission to LTC in Ontario was amended in 2010, with individuals now required to have “high or very high physical and cognitive challenges” to qualify for care. As a result, LTC home residents require a greater complexity of care, as reflected by the fact that an estimated 81% reportedly suffer from some form of cognitive impairment. To meet the increasing needs of residents in a sector that is severely understaffed, the role of PSWs has evolved to take on a greater responsibility in resident care and provide levels of support that are often beyond the scope of their training. As unregulated healthcare professionals, PSWs operate under the direct supervision of a nurse practitioner (NP) and face limited autonomy, strict reporting requirements, low wages, and minimal opportunities for further advancement. These factors contribute to the high staff turnover rates that exist for PSWs in LTC; 25% of PSWs leave the sector after just two years of work experience and 40% leave within the first year of graduation. This article will investigate the various factors that contribute to the high rate of PSW turnover, examine the COVID-19 pandemic and the staffing crisis, and highlight possible interventions that may improve staff retention within the LTC sector.

Development of Minimum Data Set-based Individualized Care Pathways for Chronic Obstructive Pulmonary Disease Treatment in Nursing Home Residents

Assessment of chronic obstructive pulmonary disease (COPD) severity in nursing home (NH) residents is limited by data requirements and lack of specialty staff, equipment, or resident ability. The Minimum Data Set (MDS) is a clinical assessment of functional capabilities and health needs completed for all NH residents in Medicare and/or Medicaid-certified long-term care homes. The objective of this study was to develop a map from the MDS to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) A-D staging of COPD severity to aid the selection of COPD treatment for NH residents.

Evaluating the Implementation of the Conversation Starter Kit in Long Term Care.

IntroductionAdvance care planning can improve the quality of life for residents in long-term care homes and reduce stress for families. However, care home staff and families often lack knowledge about advance care planning, making it especially difficult for residents with dementia to communicate their care plan wishes. A Conversation Starter Kit may increase advance care planning awareness among staff and families.ObjectivesThis study evaluated an advance care planning intervention, the Conversation Starter Kit booklet, for use in long term care homes.MethodsData were collected at three long-term care homes in southern Ontario. We collected data from 55 residents who were able to make decisions on their own paired with 11 family members of these residents. We also collected data from 24 family members of residents who were unable to make decisions on their own. This study used a quasi-experimental, one group pre/post design. Quantitative surveys were administered before and after a three-month advance care planning intervention. An additional structured interview was completed at the end of the intervention period, which included both closed and open-ended questions to assess perceptions about the booklet's use or non-use.ResultsResidents reported more engagement in advance care planning after completing the Conversation Starter Kit booklet, particularly related to asking questions to health care providers about health care decisions. Family members reported feeling very certain that they would be able to make decisions on behalf of the resident but felt less certain after completing the booklet, implying the booklet raised their awareness of the types of decisions they might need to make, hopefully prompting them to be more prepared for decisions in the future.ConclusionsAn advance care planning intervention – The Conversation Starter Kit booklet - appears acceptable and easy to use for residents and family members/friends in long-term care and can improve resident engagement in advance care planning. Although using the booklet may decrease efficacy for decision making among family members of long-term care residents, it may highlight the importance of more actionable engagement in advance care planning among residents, their families/friends, and staff.

The Integration of Long-Term Care and Personal Support Worker Education: Evaluation of a Living Classroom Experience

The shortage of Personal Support Workers (PSW) to meet the needs of residents in long-term care (LTC) homes has been well documented, and the issue has been made more acute in the context of the global COVID-19 pandemic. The living classroom (LC) has been implemented as one approach to addressing the need to train PSWs and attract them to the sector. A mixed-methods program evaluation of a LC program was undertaken. Surveys were carried out with students during and at the end of the program. Focus groups and individual interviews were carried out with staff, residents, and students. Program implementation was successful, and several program graduates were employed in the LTC home upon graduation. Key stakeholders were satisfied with the program, and students had improved attitudes toward the LTC sector. Opportunities for improvement were noted and addressed. The LC model is an approach that can be used by LTC homes and their educational partners to deliver high quality, integrated PSW programs. It can be used to help address the serious staffing shortages in the LTC sector.

Feasibility Study of a Digital Screen-Based Calming Device for Managing BPSD During Care

MindfulGarden (MG) is a digital device resembling a flat screen TV, with touchless sensors that react to voice and motion. In this study 13 long-term care home residents aged 74-100 exhibiting Behavioural and Psychological Symptoms of Dementia (BPSD) were randomized to treatment and control groups. On days 1-3 the treatment group received usual care plus exposure to MG during morning and evening care - events well documented to be problematic for residents and care staff; controls received usual care only. On day 4 both groups were exposed to MG with verbal cueing. A 26-item checklist was used to record frequency and types of disruptive BPSD exhibited; care duration was recorded in minutes. There was a trend toward reduction of BPSD and duration of care during morning care. Findings suggest that verbal cueing may be important for successful implementation of MG in calming residents with dementia during routine care.

Digital Interventions to Promote Health and Well-Being of Older Adults

The population of older adults is on the rise and so is their adoption of technology. According to the Pew Research Center, growing numbers of older adults are using smartphones, tablets, and the internet. Technology can also be an innovative and accessible way to deliver interventions that promote positive health outcomes. But implementing and evaluating digital interventions, especially those targeted to cognitively frail or otherwise vulnerable older adults, is not easy. The first presentation in this international interdisciplinary symposium sets the stage for discussing some of the barriers encountered. Specifically, it addresses the issue of compliance of adults with Mild Cognitive Impairment (MCI) while using internet-based cognitive behavioral therapy for sleep disturbance. The second presentation described a digital tool to screen and interview older adults in a hospital emergency department who may be experiencing mistreatment. This is followed by a study of use of voice assistant reminders to help aging adults adhere to daily completion of a diary to self-monitor pain symptoms. The fourth presentation describes a feasibility study of a digital screen-based device to calm long-term care home residents exhibiting disruptive Behavioral and Psychological Symptoms of Dementia. Symposium speakers and participants will be encouraged to dialogue on how some of the implementation and evaluation barriers described might be overcome or avoided as well as to share success stories from their own research on digital interventions for older adults living at home, in congregate housing or in hospital settings.

Structures, tensions, and processes shaping long-term care home staff's role in end of life decision-making for residents with dementia

Although long-term care (LTC) home staff of nurses and personal support workers spend the most time providing direct care, their role in end of life decision-making for residents with dementia has largely been unacknowledged. Staff's perceptions of their role play a significant part in how they support people with dementia and family care partners. The purpose of this study was to examine LTC home staff's perspectives of their role in end of life decision-making for LTC home residents with dementia.For this interpretive descriptive study, 21 semi-structured interviews were conducted in two urban LTC homes with nine personal support worker (PSWs), eight registered practical nurses (RPNs), and four registered nurses (RNs). Additionally, a focus group was conducted, consisting of each a PSW, RPN, and RN. A voice-centred relational analysis was used to situate LTC home staff's perspectives within broader social contexts. Findings suggest that little has changed in LTC homes in the last 50 years. Rooted in dichotomies between medical and social care paradigms, ideologies of rationality and professionalism created tensions, hierarchical roles, and staff's minimal involvement in decision-making. A relational approach is needed to account for the interdependency of care and the relationships that LTC home staff have with residents, family care partners, and the sociopolitical environment.

Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study.

The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.