Monday, May 2, 2016

Living Up to the Promise

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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