Current and Future State of Continuing Care in Canada

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Current and Future State of Continuing Care in
Canada

• Margaret MacAdam, Ph.D.
• The Age Advantage

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What is Continuing Care?

• Continuing Care typically refers to the full
  array of services for those with chronic
  conditions
• It includes residential options such as
• Chronic care hospitals
• Nursing Homes
• Assisted living facilities
• Retirement homes
• In-home and community services
• Home care
• Community support services such as day programs

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But

• It should also include the provision of
• Primary care
• Specialized medical care
• Hospital and
• Rehabilitation services

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In this talk

• I will focus especially on nursing home care but
  will speak about it in the context of changes
  happening throughout the health and social care
  delivery system
• I use the term nursing home to refer to
  government-licensed and funded facilities
  offering 24/7 nursing, social and hotel services
  to those qualifying for admission.

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Is a nursing home where I will live?
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The size of the nursing home sector

• The nursing home sector is about a 10B dollar
  industry in Canada
• The sector is the fifth largest area of health
  spending (after hospitals, drugs, physicians, and
  other professionals)
• Nursing homes are the final home of almost
  300,000 Canadians living with disabilities

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• We will review key issues about
• Demand
• Supply
• Quality of care in nursing homes
• and
• Present some implications for the future

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Demand for nursing home care

• Demand for nursing homes is driven by
• Type of care need for daily care in bathing,
  dressing, eating, toileting, medication
  administration, and behaviourial supervision
• in conjunction with
• Lack of cost-effective alternative care options
  no/inadequate family support, lack of
  community-based alternatives, inability to
  privately pay for care

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Characteristics of nursing home residents

• There are about 299,390 residents in nursing
  homes at any given time
• about 1 of the total population
• 83 of residents are over age 65
• 5.5 of the elderly live in nursing homes
• Younger residents are growing in numbers and have
  unique medical, health and social needs
• Most residents are female
• Acuity levels are increasing (more g tubes,
  catheters, oxygen, etc) LOS is decreasing
• Source Statistics Canada, 2006 Census of
  Population

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Positive demand is driven by

• Population Aging
• Disability levels are stabilizing in the elderly
  population (and perhaps decreasing)
• But the absolute number of those with
  disabilities is increasing
• 80 population is increasing faster than other
  age group
• Source Freedman et al, 2002, Fuller-Thompson et
  al, 2009

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Negative demand is driven by two factors

• 1. Consumer Preference
• The coming surge of retirees wont settle for
  a miserable life in an institutional-style old
  folks home. They want their independence, they
  want to party, they want to have sex into their
  80s.
• Pearson, P. 2009. The Golden Oldies. Toronto Life
  

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Negative Demand

• 2. Government Policy
• Governments are investing in less costly
  alternatives to nursing homes such as in-home
  care, assisted living, group homes, other
  community programs
• The goal is to satisfy consumer demand for
  alternatives to nursing home care and manage the
  health care budget
• Alberta recently announced that they may reduce
  the supply of nursing homes beds and increase
  assisted living beds.
• BC built 5000 assisted living beds instead of
  nursing home beds

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Distribution of Government Health
Expenditures by Age Group, 1998, 2001 and 2004

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Supply

• There are from 2,102 to 2,577 nursing home
  facilities in Canada
• These facilities contain from 193,451 to 217,969
  beds,
• From 49-54 of beds are owned by the private
  sector
• Total expenditures are about 10B
• Sources Canadian Healthcare Association.
  (2007). Guide to Canadian Healthcare Facilities
  2007- 08. Ottawa.
• Statistics Canada, Residential Facility Survey
  2005/2006

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Supply is influenced by

• Government policy
• Owners need government permission to build new
  homes, or add to/ subtract from current bed
  supply
• There has been a shift to for-profit facilities
  in some provinces

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Supply Waiting Lists

• Every province has waiting lists for nursing
  homes
• In Ontario, occupancy is 98-99, wait times for
  nursing home placement doubled in the last two
  years, now 25,000 people are waiting an average
  of 106 days
• About 10 of applicants to nursing homes are
  waiting in acute care hospitals In Ontario
• The national goal of reducing wait times for
  hospital care is putting pressure on governments
  to increase residential LTC supply (and community
  options)
• Source LTC Wait list, Ontario. August 2009

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Supply

• In 2008, all provinces indicated that they were
  planning to increase LTC beds
• Note Alberta has since frozen its nursing home
  bed supply, the BC government seems to include
  assisted living spaces in its count of LTC beds
• Source MacAdam (2009). Moving Toward Health
  Service Integration Provincial Progress in
  System Change for Seniors. www.cprn.org

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In summary

• No one seems to want more nursing homes but
• There are long waiting lists for admission and
• Many provinces are planning (VERY reluctantly) to
  increase LTC bed supply
• Advocates for the elderly in BC and Alberta are
  calling for more beds to be built

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Issues Quality of Care

• Quality of care issues are evidenced by pressure
  ulcers, medication errors, falls, resident
  aggression, treatable depression and infections
• In Ontario, 4 of elders in LTC homes are
  receiving drugs that are known to be dangerous
• Some residents are being needlessly sent to
  hospital emergency departments
• Canadian nursing homes seem to use restraints
  much more often than those in some other
  countries
• But 90 of residents rate the quality of care
  they receive as good to excellent (Ontario)
• Source Canadian Patient Safety Institute (2008)
• Ontario Quality Council, 2008

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Quality

• The Canadian Patient Safety Institute published a
  paper in 2008 calling for a stronger research
  program to identify leading practices in caring
  for residents in nursing homes.
• Issues included staff skills, inadequate
  inter-disciplinary communication, and
  communications with family members

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Quality is affected by

• Supply and Training of Staff
• Nursing
• When nursing funding is inadequate,
  administrators reduce the RN workforce and
  increase the RPN and personal support workers.
• Many would argue that too few RNs increases the
  risk of poor quality of care
• Source Canadian Healthcare Association (2009)

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Quality

• Medicine
• 22 of family physicians in Canada include one or
  more nursing homes as practice site
• Only 1.2 report a nursing home as their main
  care setting
• Shortage of geriatricians (211 geriatricians
  estimated need is 538)
• There is an urgent need for more geriatric
  psychiatry in nursing homes
• Source National Physician Survey, 2008
• Hogan (2007)

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Medical Training

• There is inadequate training of physicians in
  care of the elderly
• Rotations in geriatric medicine are not mandatory
• Dalziel estimates that students spend only 1 of
  4 year medical school curriculum working with the
  elderly but
• MDs may spend 70 of their career time with
  elderly patients
• Source Canadian Healthcare Association, 2009.
  P. 99

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Continuing Care The Policy Issues

• Uneven access to continuing care services is a
  major policy issue
• Long term care, whether provided in the
  community or in facilities is not an insured
  service under the Canada Health Act
• It does not receive the sustained attention that
  services covered under the Act receive.
• There is unequal access to care across the
  country
• Standards for care vary from one province to
  another
• Cost effective service delivery is also a major
  policy issue
• Policy makers are trying to develop a
  community-based care system and to use nursing
  home beds as effectively as possible

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Trends

• Disability levels seem to be stabilizing but it
  is likely that acuity levels among nursing home
  residents will continue to rise
• Consumer demand will increase pressure to improve
  quality of care, resident privacy,
  decision-making and amenities
• Consumer demand will also insist on increased
  alternatives such as more care in the community,
  alternative 24 hour options such as lower level
  facilities

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The Great Unknowns

• The arrival of new technologies such as an
  effective treatment for Alzheimer Disease
• The arrival of a pandemic that especially affects
  the elderly
• The effectiveness of health reforms that
  encourage care in other settings

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Speculative Thoughts

• There will always be a need for nursing homes
• But
• The acuity levels of residents will continue to
  rise and funding levels will have to increase to
  compensate for the need for more nursing
• Staff training will continue to be a pressing
  issue
• Physicians will be expected to be more available
• There will be greater pressure to provide
  palliative care and certain other advanced
  treatments in facilities
• Physicians will need more support for example,
  more advanced practice nurses on staff
  electronic records, and prescription ordering
  and disease management guidelines.

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Recommendations

• Adequate and sustainable funding for nursing
  homes
• Focus on quality and accountability in
  performance management
• Invest in human resources
• Develop a culture of caring which
• Addresses the psychological, social and
  spiritual aspects of life
• Addresses family and resident needs at
  end-of-life
• Implements a home-like environment
• Source Adapted from Canadian Healthcare
  Association 2009

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Last Thoughts

• There is a great a need for advocacy on behalf of
  residents of nursing homes
• Physicians, especially through the large powerful
  groups such as the Canadian Medical Association,
  can be leaders in advocacy efforts
• There is a great need for more research about
  best practices in nursing home care

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She shouldnt have to worry!
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More Information?

• Margaret MacAdam, Ph.D.
• President, The Age Advantage, Inc.
• info_at_theageadvantage.ca