I recently read a
report called Living Up to the Promise which looked at housing
options for seniors in BC. The report is called Addressing the High Cost
of Underfunding and Fragmentation in BC’s Home Support System it was written
byh By Marcy Cohen & Joanne Franko and published by the Integrated Care
Advocacy Group and the BC Health Coalition in May 2015
The intent of this
report is to examine whether the basic services offered through the publicly
funded home support system are currently meeting the needs of the senior
population, and how these services could be organized and delivered in future
to better support seniors to remain at home for as long as possible. I will
share some of what I think are highlights of the report, but if you want to see
the full report go here (it is a pdf file)
I have talked about
the need for us to be around people and this report touches on this
need. The World Health Organization and the Public Health
Agency of Canada
recognize social support as a key determinant of health. When seniors have
meaningful social connections, they “develop their resilience and ability
to bounce back after adversity, as well as an ability to gain strength
from stress rather than be diminished by it. ”In contrast, feeling
isolated from others can “disrupt sleep, raise blood pressure,
lower immunity, increase depression, lower overall subjective well
being and increase the stress hormone cortisol.”
In addition to
experiencing poorer emotional and physical health, socially
isolated seniors are also at a higher risk of over-consumption of
alcohol, falling, and suffering from poor nutrition. The risks of
social isolation are highest among poor and visible minority
senior populations.
Researchers recently
quantified what they refer to as the effects of the ‘loneliness disease’,
warning that lonely people are nearly twice as likely to die prematurely
compared to those who do not suffer feelings of isolation.
In a similar vein, a
2011 report from Vancouver Coastal Health’s SMART Fund highlights the
key findings from a number of studies on the health benefits of
social support for an aging population. In these studies social support proved effective
in slowing cognitive decline, the onset of dementia, and the progression
of physical disability
Related to this is
the growing recognition – from clinicians
and older adults alike – that the primary goal of health care
interventions, particularly for older seniors with significant and/or
multiple chronic conditions, should be to optimize the person’s
function and comfort rather than to treat or cure a specific disease.
This is often
referred to as restorative care or reenablement and is most often recommended
after an acute illness or hospitalization when older adults are at
particularly high-risk for functional decline. There are, in addition,
many other situations where a restorative approach to care could be
beneficial (e.g. following the death of a spouse, when the individual
moves to a new setting, etc.).
A restorative care
philosophy differs from regular home support in some specific ways.
Instead of simply having the home support worker do specific tasks for the
individual, the older adult is supported by an interdisciplinary team to
be as independent as possible. The goal is to support the older adult to
develop or redevelop the skills and confidence needed to do things for
themselves (perhaps in new ways) and to build connections with new networks
of social support.
For people living
with dementia and their families, there is very compelling evidence that
appropriately delivered early interventions can extend the time that a person
living with dementia can remain in their own home. To be effective, these
early interventions must be multi-pronged, include psycho-educational
support, active engagement and specialized training for home health
services staff, and comprehensive monitoring by a case manager.
With these elements
in place, it is possible to alleviate symptoms and behavioural problems in
persons with dementia, and reduce the negative effects of caregiving (e.g.
depression and social isolation)
The stated goal of
BC’s Ministry of Health is
In reality, access to
home support services have declined significantly in recent years. From
2001/02 to 2009/10, access to support home services for people 75 and
over declined by 30 percent and services were increasingly
restricted to those with higher, more complex needs.
In 2013-14 the
number of clients receiving home support was virtually identical
to the number receiving services in 2001-02 and yet, over those 12 intervening
years in BC, there was a 40 percent increase in the number of seniors 65
and over, and a 49 percent increase in those 80+ years.
Moreover, people are
now discharged from hospital ‘sicker and quicker’ and access to
residential care is more restricted, contributing to the increased
reliance on home support services.
To cope with growing
demand for limited resources, eligibility criteria for home support
services are becoming increasingly restrictive and seniors with moderate
needs are much less likely to be able to access publicly funded home
support services.
As a result, an
increasing number of seniors, particularly those with low income, end up
waiting until they have a health crisis and/ or are admitted to hospital
before they are offered access to home support services.
Key Findings
from the Five Focus Groups
One: Person-Centered
Care is Not an Option
The increased
pressure on the health authorities to provide more services with limited
resources has resulted in a system of very rigid protocols for the
community health workers, who are authorized to perform only a very
limited number of prescribed tasks.
These tasks are
outlined in the care plan developed by the case manager. The community
health workers are informed of the specific tasks that they are authorized
to perform and if they engage in activities not on the care plan, they
will not be covered for liability or injury and may be reprimanded by
their supervisor.
Access to the care
plan itself (which includes the client’s health history and diagnoses)
varies considerably from one area to another.
Two: Social
Support No Longer Part of the Community Health Workers’ Role.
Despite all of the
evidence on the importance of social support in ensuring that seniors can
continue to live healthy and active lives in their own homes, providing
this support is no longer part of the community health worker’s role
Three: Meaningful
and Trusting Relationships between Workers and Clients Less Likely
It is broadly
acknowledged that continuity is important to good quality outcomes for the
person receiving care. Continuity makes it possible for CHW – like other
members of the primary and community care team – to get to know their
client, establish a relationship with them and monitor and report on any
changes in their health status.
However, continuity
is more difficult to achieve with a rotating, short-term schedules and a
high proportion of casual workers. Many visits are very short (some visits
are less than 30 minutes depending on the task) so as to maximize the
number of clients that can be served on each shift. The result: today’s
community health workers are less likely to have the opportunity to
develop a meaningful and trusting relationship with their clients.
Four: Family
Caregivers Are Not Recognized or Supported
At present our
community health care system provides little support for informal
caregivers, even though family caregivers play a crucial role in
maintaining at-risk older persons in the community and should to be viewed
as part of the care team.
The participants in
the family caregiver focus group talked at length about the lack of
recognition of the needs of family caregivers by the health authorities
and home support agencies
The physician, nurse
and community health worker focus group participants commented that
increasingly, instead of being part of a proactive plan to support seniors
to live well in their own homes for as long as possible, care is usually
put in place in response to a crisis.
They also noted that
there is very little focus on restorative care for people who are at risk
of functional decline but who, if supported to develop their skills and
confidence to do things for themselves could be more independent, would
have better health outcomes and reduced service costs
The report made the
following two recommendations that the Ministry of Health:
1. Provide the
funding for home support that is required to increase staffing levels, teamwork
and training, and to increase the number of case managers, community
rehabilitation staff, registered nurses and licensed practical nurses available
to support community health workers in providing care to older adults at home
with chronic, acute and palliative care needs.
The funding should be
based on a plan that includes significant targeted yearly increases over the
next ten years tied to the system improvements outlined in the second
recommendation below.
From 2009-10 to
2013-14, the number of clients receiving home support services from the health
authorities increased from 32,768 to 38,802, and costs increased by $49
million, an increase on average of 3.25 percent a year.65 This increase
effectively meant that the same number of home support clients received
services in 2013 as in 2001, and yet over those 12 years, there has been a 49
percent increase in the number of seniors over 80.
2. Develop a plan for
how to align BC’s home support delivery system with current research on
what is needed to provide high quality, cost effective services that are inclusive
of family caregivers, support seniors to bettermanage their chronic physical
and mental health challenges, and ensure that seniors can remain as
independent and socially engaged as possible.
The plan would
include the following key elements:
· An advisory committee
to guide the change process with representation from: family caregiver
groups, seniors’ organizations, community agencies providing social
supports to seniors, health policy experts, and front line providers
(i.e. nurses, family doctors, community health workers).
· A priority focus on
early interventions and prevention to ensure that seniors’ need for social
support, good nutrition, exercise and other basic services are addressed
by both the home support system and through better co-ordination
and linkages with community agencies providing social
support services to seniors.
· A restorative
team-based model of care for seniors following an acute illness and/or
hospitalization to restore independence and reduce functional decline, and
training for community health workers to ensure they play a lead role
in providing this care.
· A process for
ensuring that all community health workers have access to information on
their clients’ medical history prior to their first visit, and that this
information is regularly updated and available to the family physicians as
well as the home and community care staff supporting the client.
· Systemic recognition
of the role of community health worker in preventing health crises
including the expectation that their input will be acknowledged and
appropriately addressed, and a protocol developed to inform the family
physician/ nurse practitioner in case of a crisis or acute medical issue.
· New opportunities and
training for community health workers to work in teams with case managers,
nurses and/or family physicians in caring for clients with advancing dementia,
severe and/or multiple chronic ailments and/or in need of palliative care.
·
Inclusion of the family caregivers as full members
of the care team with access to respite care, social support and education as
needed
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