Capstone final project charter July 22, 2021

TOPIC: - “Mental health in LTC (long term care) residents related to pandemic/lockdown”.

INTRODUCTION

Long term includes a number of services designed to meet individual’s health and

personal needs for a long period of time when they are no longer able to perform their routine

activities (bathing, walking, eating, toileting, dressing) by their own due to chronic disease or

disability. These services can be provided at home, nursing homes, adult day care centres, or

long-term facilities by the health care providers. The people living in facilities were often

visited earlier by their families, friends or loved ones but during pandemic all visits are

restricted by the government which in result affecting the mental status of clients at LTCs due

to loneliness, isolation, anxiety and fear of contracting covid-19. All the clients are spending

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time watching TV alone in their rooms, hearing news on radio about people dying due to

covid-19 leading to emotional disruption. All day programs, recreational and outdoor

activities are closed. Depression, anxiety and dementia are most common mental illnesses

which are affecting the residents of LTCs as it is well known that the clients with dementia

when get disoriented needs support and reassurance of the family which is hard to provide

due to lockdown. Even the staff are not able to soothe, support and reorient them due to

blocking of facial expressions by masks.

BACKGROUND

The COVID-19 has affected the mental health of residents directly through infection,

and indirectly, through social isolation. Residents of long-term care (LTC) facilities are often

frail with multiple comorbidities, poor physical function, cognitive impairment and

depression. For the past one year, LTC residents have been confined to their rooms without

any outdoor activities, family or loved one’s visits, lack of exercise, direct sunlight and fresh

air, social interaction. They are even surrounded by staff members wearing mask, gown and

face shields all the times which hinders their interaction with staff too feeling them lonely.

Throughout the pandemic, Canada has the highest global rate of all COVID-19 deaths among

LTC residents. Hence, many recommendations have been created to improve care in LTCs

but none of them have focused on the mental health in LTCs residents.

“In August 2020, the CDC published a survey of more than 5,000 adults. The older adults

surveyed reported significantly lower percentages of anxiety disorder (6.2 percent) depressive

disorder (5.8 percent) or trauma- or stress-related disorder (TSRD) (9.2 percent) than

participants in younger age groups”[ CITATION Reg21 \l 1033 ]. Whereas, in long term

facilities 23.3 percent of the residents are diagnosed with depression and 44 percent residents

have depressive symptoms [ CITATION Mat191 \l 1033 ]. Approximately, more than two in

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five Canadian seniors living in LTC are diagnosed with or have symptoms of

depression[ CITATION CIH10 \l 1033 ].

What is known about the problem?

Depression is very common problem both in seniors and youngers arises due to

loneliness, stress, social isolation and sometimes due to dementia.

What is not known?

How to handle the clients at LTCs with depression and how to overcome their

loneliness. Moreover, how to contact the family, friends or loved ones during visiting

restrictions due to lockdown.

PROBLEM STATEMENT

Impaired mental health of the residents in long term facilities due to loneliness, social

isolation, visitor’s restrictions and lack of interaction with care givers during

lockdown/pandemic is not only affecting the mental health of residents but also increasing

the financial burden over organizations/government in treatment of mental health issues.

Disturbed mental health of the residents can lead to anger, anxiety, fear, sadness and feeling

of helplessness and hopelessness, changes in mood, impulsive or aggressive actions which

can harm the staff who will be working in LTC. Even the resident with depression can try to

commit suicide or self-harm.

PROJECT OBJECTIVES

 Specific: - The specific objective is to assess the reasons for mental health disturbances in

clients at LTCs and their solutions. Moreover, to create connection and communication

between care givers and the residents at the facility.

 Measurable: - The method which we will using to measure the outcomes after successful

communication and interaction of staff with the clients like care givers must reassure the

residents at the time of aggression, anger or anxiety.

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 Attainable: - Our attainable objective is to invite the family members on video or zoom call

with the clients to relieve the loneliness. Online counselling session should be organized to

improve their mental health.

 Realistic: - To lessen the incidence rate of depression, anxiety, sadness, suicidal ideation in

the residents at long term care due to pandemic which are the highest in Canada.

 Time-bound: - The time frame for the achievement of objectives is two months i.e., by

September which helps to achieve the set objectives as soon as possible.

OUTPUT METRICS

The signs of progress in improved mental health can be measured by their involvement

in indoor activities, control over emotions, feeling of loved and cared at LTCs, behaving

good with family on calls and mingling with other clients at the facility.

ANALYSIS METHODS

There are several analysis tools available to find the cause of the problem. In order to

find how the mental health of the residents are affected, we are going to use five why analysis

method and the fish bone diagram method to find the root cause of the issue. Using the

analytic tools improves the quality of work and to find the actual solution to the problem.

FIVE WHY’S ANALYSIS

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WHY IS THE MENTAL HEALTH OF THE LONG TERM

RESIDENTS ARE AFFECTED?
The long term residents are suffering from depression, dementia due to lack
of social interaction

WHY THERE IS LACK OF SOCIAL INTERACTION IN THE

LONG TERM CARE?
The families didnot show up to the long term care and there is also no
public intervention or volunteer support to the center.

WHY DIDN'T THE FAMILIES SHOW UP?

Since there is lockdown in the country the families are unable to visit the
residents like usual.

WHY THERE IS LOCK DOWN IN THE COUNTRY?

The government has implemented strict travel restrictions so the families are
unable to meet the residents.

WHY DID THE GOVERNMENT IMPLEMENTES STRICT

RULES?
To reduce the spread of the COVID 19 pandemic, the government has
implemented strict rules to reduce the spread of the disease.

The five why analysis is an analytical tool used for finding the root cause of the

problem in five simple steps. In this current situation, the residents of the long-term care are

suffering from several mental health issues like depression, dementia, loneliness and some

phobias like claustrophobia as a result of staying indoor. This is because lack of support from

the families and the other stakeholders due to the pandemic has led to negative mental health.

FISHBONE DIAGRAM OR THE CAUSE-AND-EFFECT DIAGRAM

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ROOT CAUSE OF THE PROBLEM

From the 5 why analysis and the fishbone diagram the root causes of the mental

illness in the long-term care residents can be identified properly. The pandemic has changed

our lives completely as the government has enacted strict rules to stay indoors to prevent the

transmission of the disease. Isolation, lack of family contact, lack of social activities,

loneliness puts pressure on these individuals leading to worsening of their mental health. The

analysis can be made simple with the following six steps.

 Define the event: Mental health of long-term care residents due to pandemic

 Causes: Isolation, lack of social intervention and staying away from loved ones

 Finding the root cause: Isolation for a longer time

 Find solutions: Spending time with the loved ones virtually and implementing fun activities

in the long-term care facility.

 Take action: Group sessions to overcome depression

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 Verify solution effectiveness: Private sessions with the long-term care residents about the

fun activities and the virtual calls.

STAKEHOLDERS AND THEIR IMPORTANCE

From the diagram, the stakeholders include physicians, residents, family members,

advanced practice registered nurses and administrators. Among these, the families and the

nurses are the key stakeholders. I would like to discuss the major stakeholders.

1. Family members:

The residents of long-term care are usually senior citizens who require lots of love, care

and affection. The family members are unable to take care of them at home due to various

reasons but they should be responsible to engage them even though they stay away from

them. During the pandemic, the family members are unable to meet them because of the

travel restriction. But they should be responsible for their elder ones and they should call the

long-term facility to enquire about the well-being of the residents. The family members can

seek the permission of the government to permit them to meet the residents as one person per

family with extreme protective measures. On the other hand, the long-term care facility can

arrange for the families to meet the residents virtually so the loneliness can be brought down.

2. Nurses:

The next most important stakeholders are the nurses as they spend a large amount of time

with them not only by providing medications but also by taking care of their daily routine

activities and mental health. The nurses are the first person to identify any changes in the

resident’s physical and mental health. From the cause identified, the nurses can have therapy

sessions with the residents and they can enquire about the needs of the residents. They can

also develop a good rapport with residents and make them indulge in activities like group

discussions or any fun activities. The nurses can bring the evidence-based practice into the

actual practice and they can act as the real heroes in situations like pandemic.

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SOLUTION TO THE PROBLEM

The residents are made to talk with their families through zoom sessions and made to

talk with social reformers who visit the long-term care. The long-term care can arrange for

student volunteers who can talk with the residents and also providing counselling sessions to

them to overcome stress. The recent upliftment of the restriction in Ontario can help the

families to meet their parents in the long-term care facilities thereby helping them

furthermore. The nurses along with the families can work efficiently thereby preventing the

patients from mental illness.

IMPACT/EFFORT MATRIX

These solutions are to improve the mental health of the residents. These solutions can

be implemented following the COVID restrictions according to public health of Canada.

a. Volunteers to speak with residents – having volunteers to engage and speak with the

residents can reduce loneliness.

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b. Staff asking residents about how they feel and getting to talk more about their feelings-

this is a very important one. Apart from helping the residents with their basic needs, it is

crucial for the staff to get the residents to talk. This will promote trust and encourage

residents to speak about their feelings.

c. Engaging residents in more physical activity, e.g., going for a walk within the facility-

changing one’s scenery sometimes goes a long way in improving mental health. Having

the residents go for walks will improve their moods.

d. Planning programs such as creative and Innovative activities to engage residents- arts

and crafts is always a good way to start. Having the residents continue with programs

like this and planning celebratory meals and snacks for them will go a long way in

improving their mental health.

e. Planning drive-throughs with residents’ family- This might be a bit difficult to do but

will make a significant impact. Since visitors are not allowed into the facility, a drive-

through program where families and residents can see each other without contact might

help the residents feel they are not alone and their families still care for them.

f. Workout, music/art therapy- working out improves one’s mood, although not every

resident might be able to work out. Engaging the residents in things outside the norm

might go a long way in bettering their moods.

g. Residents/ being able to visit home/family- This solution can only be possible if there are

lesser number of Covid cases in the community. If the residents are able to visit their

families, this will mean that things are returning to normal for them which will positively

improve their mental health.

h. Lifting some or all of lockdown restrictions- lifting the lockdown restrictions will mean

that everyone’s life can return to normal including the residents.

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i. Residents having access to malls and stores like they used to- doing fun things like going

to the mall and seeing other people will put residents into better moods.

IMPLEMENTATION PLAN

What How With what Who By when

Volunteers to speak Hiring the through flyers Management Every time
with residents volunteers and social media of LTC
platforms
Staff asking residents Engaging more With the Staffs from Every time
about how they feel time with LTC experience and the LTC
and getting to talk residents knowledge what
more about their they have
feeling
Planning programs Conducting With the Management 15 days
such as creative and indoor games residents and and staff
innovative activities and their familiar members
to engage residents extracurricular
activity
Engaging residents in going for a walk With the Staffs and Twice a
more physical within the residents and the volunteers
activity, facility location, they week
used to
Planning drive- Taking the With the Management On Sundays
throughs with residents to vehicles and and the
residents’ family their family drivers from the drivers of the only
members by LTC LTC
drive through
Workout, music/art Entertaining the With the Staffs and 2 days a
therapy exercise and facilities volunteers
playing available in the week
background LTC
music
throughout the
facility
Residents /being able Allowing the With the Management Twice a
to visit home/family residents to visit vehicles and of the LTC
home/family drivers from the month
with strict LTC
protocols
Residents having Taking the With the Managements Once a
access to malls and residents to the vehicles and and
stores like they used malls and stores drivers from the government month
to like they used to LTC officials

The COVID-19 pandemic, which was caused by the SARS-CoV-2 virus, disproportionately

affected older adults and people with pre-existing health issues, who experienced more severe

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disease and had worse outcomes. Those who work or live-in close quarters are at a higher

risk of infection. As a result, residents of long-term care (LTC) facilities have been

disproportionately exposed to SARS-CoV2 infection and devastating COVID-19

consequences, including death.

Following can also be considered mainly in the implementation plan;

 Ensuring that adequate human and physical resources are available for the care of inhabitant.

 Increasing municipal health and hospital systems' assistance for the LTC industry.

 Infection prevention training and control for LTC staff should be improved.

 Engaging the long-term care residents, going for a walk within the facility and entertaining

the workout, music and art therapy.

 Informing all the staff members in the long-term care centre to ask the residents about how

they feel and getting to talk more, listening to them.

Over all else, the experts believe that long-term care facilities are living environments,

and that a human and caring attitude to patients, their families, and the workers who care for

them is important. Although considering short-term solutions, the task group concluded that

the difficulties encountered are symptomatic of larger systemic concerns that contribute to the

severity and results of the COVID-19 crisis in long-term care facilities.

TIME FRAME FOR THE PROJECT

Project development: Two months to define problem, findings resources and measures, and

plan for implementing the solutions.

Implementation: One month

Evaluation of outcomes: August 2021

BARRIERS TO IMPLEMENTING SOLUTIONS

1. Extremely strict visitor restrictions:

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Participants described visitor policies as being overly strict, resulting in the loss of

important family members in care as well as formal and informal interpreters. Family

caregivers were regarded as the "unseen" caregivers. PSWs have a lot of assistance, and this

resource was created to help them. With the installation of visiting limits, this problem was

solved.

2. Harm of lack of family presence:

The psychological impact of not having visitors was regarded as critical for both

individuals and their families; restricting this touch with loved ones caused desperation and

depression. Family member’s presence can be a huge assistance, especially for people with

advanced dementia or those who don't speak the same language as their professional

caregivers.

3. Technology challenges:

Throughout the pandemic, it has been difficult to coordinate technology. Limited access

and residents' lack of experience or comfort with technology have been obstacles.

4. Staff shortages:

LTC have been chronically understaffed. Workforces typically include mostly part-time

or casual workers with low wages and high turnover. Staff shortages during the pandemic

have been exacerbated by illness, fear, the one-site limit per staff, and the loss of

family/essential care visitors with visitor restrictions.

5. COVID-19 IPAC protocols result in increased workload:

Staff have been burdened by the added workload associated with implementing

pandemic IPAC protocols. This includes more time spent on increased cleaning measures and

donning and doffing personal protective equipment (PPE), as well as less available workers

caring for the same number of residents.

TESTING THE OUTCOMES

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1. COVID-19 has disproportionately affected long-term care and retirement homes in

Canada, and the pandemic experience for the sector has not improved in the second

wave.

The second wave of COVID-19 in Canada was larger and broader than the first,

spreading across the country and causing more outbreaks, illnesses, and deaths in long-term

care and retirement facilities. The pandemic's impact differed widely across provinces and

territories, as well as between COVID-19 waves.

2. During the first wave of COVID-19, LTC residents received less medical attention than

in normal years.

LTC residents had fewer physician visits and were less frequently transferred to

hospitals for the management of chronic illnesses and infections during the pre-pandemic

years. They also had fewer social interactions with friends and family, which was related to

increased depression rates.

3. During the initial wave of the pandemic, the number of LTC residents who died was

higher than usual.

Even in parts of the country with fewer COVID-19 cases and/or outbreaks, the total

number of resident deaths from all causes was increased during the first wave lockdown than

in the same period in pre-pandemic years in all provinces where it could be measured.

4. COVID-19 in LTC homes recommendations from provincial and national inquiries to

date are similar and speak to structural difficulties in the profession.

To reduce crowding and illness spread, more staff is needed, as well as greater infection

control and prevention procedures, better inspection and enforcement processes, and

enhanced building architecture.

While there are numerous sources of information on the impact of COVID-19 on the

Canadian population as a whole, timely information on the number of confirmed COVID-19

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cases in Canadian long-term care facilities is slower to access through it. Based on publicly

available information, we estimate that less than 2% of long-term care home residents in

Canada have been diagnosed with COVID-19, but that deaths in this population represent

about 43% of all COVID-19 deaths (excluding Québec, where the overall number of deaths

from long-term care homes has not been reported). Residents in Canadian long-term care

homes have case fatality rate of about 17% (Ranges between 15 to 19 per cent, based on best

estimates of available data from Ontario, British Columbia and Alberta). [ CITATION

Amy20 \l 1033 ]. This is almost the same as the global case fatality rate for those over the age

of 80. Infection prevention is the most successful technique for reducing total fatality in this

population, given the fragility of individuals in long-term care institutions.

Standardize and Sustain Solutions

Budget

Regulatory costs $400 00

Transportation
$500 00
Food
$1000 00
Materials for Creative and Innovative activities
$500 00
Music/art therapy
$1000 00
Total
$3400 00

This budget is an estimate for a monthly spending. Budget might change, depending

on how often staff want to engage residents. However, this is a summary of how much would

be needed if every one of the solutions listed above are followed every month.

CONCLUSION

The residents of the long-term care are usually seniors who deserve love, care and

affection. Though the COVID 19 has changed lives completely, alternate steps can be made

to take proper care of the residents. Mental health is equally important as that of physical

health and any mental illness should be identified early to prevent permanent damage. By

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providing proper care and affection the mental health of the residents can be maintained

positive all the time.

REFERENCES

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i. Amy T. Hsu and Natasha Lane; 2020, April 15, Impact of COVID-19 on residents of

Canada’s long-term care homes — ongoing challenges and policy response.

Resources to Support Community and Institutional Long-Term Care Responses to

COVID-19. https://ltccovid.org/2020/04/15/impact-of-covid-19-on-residents-of-

canadas-long-term-care-homes-ongoing-challenges-and-policy-response

ii. Identifying Barriers, Facilitators and Recommendations to Long-term Care COVID-

19 Infection Prevention and Control Preparedness and Response; 2021-01-21.

Retrieved from; https://www.cfhi-fcass.ca/docs/default-source/itr/tools-and-

resources/cfhi-ltc-barriers-facilitators-and-needs-report_18dec2020-final.pdf?

sfvrsn=7010ca0f_2

iii. Mary Beth Nierengarten, June 2, 2021; COVID and the Ongoing Mental Health

Needs of Long- Term Care Residents. Retrieved from;

https://pro.psycom.net/special_reports/covid-and-mental-health-long-term-care-

residents

iv. Matthias Hoben, Abigail Heninger, Jayna Holroyd-Leduc, Jennifer Knopp-Sihota,

Carole Estabrooks & Zahra Goodarzi; December 2, 2019; Depressive symptoms in

long term care facilities in Western Canada: Retrieved from;

https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1298-5

v. Regina Koepp, January 11, 2021; How Is the Pandemic Affecting the Mental Health

of Seniors? Retrieved from; https://www.psychologytoday.com/us/blog/the-

psychology-aging/202101/how-is-the-pandemic-affecting-the-mental-health-

seniors

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