campaign - Seniors

At present, the provision of long term care services (LTC) in Alberta and throughout Canada has failed to keep pace with increased need, resulting in unnecessary suffering for people and greater costs for patients, their families and the public purse. Albertans now have a situation where an inordinate number of acute care hospital beds are occupied by ‘alternate level of care’ patients. These are people who no longer require treatment in an acute care hospital, but are awaiting placement in LTC beds that simply do not yet exist.

This chronic shortage of LTC beds doesn’t only affect seniors. It has adverse effects on all of us − except the corporate interests that have taken over much of seniors care. Our whole health care system is suffering because of the failure to deal effectively with LTC.

What is Long‐Term Care (LTC)?

Long‐term care is a small part of what the government defines as its Continuing Care system. Continuing care covers everything from Home Care, the four levels of Supportive Living and what the government calls Facility Living, which is LTC. The government frequently announces the opening of Continuing Care beds or spaces, but that does not necessarily mean LTC beds.

The Government of Alberta defines long‐term care as care received in either a Nursing Home or Auxiliary Hospital. Adults assessed by Alberta Health Services as having complex and unpredictable medical needs requiring a Registered Nurse to be on site 24/7, meet the criteria for placement in these facilities. Once in such a facility, residents are, by Alberta’s current definition, receiving long‐term care.

LTC costs are not fully covered under the Canada Health Act ‐ i.e. not covered by “Medicare.” Depending on the number of residents per room, individuals in Alberta currently pay $50 to $60 per day to cover the cost of accommodation, meals and housekeeping. However, the cost of basic personal and medical care, pharmaceuticals or supplies is covered by AHS for residents in Alberta LTC facilities.

While it is true that many individuals would much prefer to remain in their own homes or in other less medicalized settings, a small percentage inevitably reach a point where even the best supportive living or home care system cannot provide the 24‐hour care and monitoring they require and they do need long‐term care.

What is the need for LTC?

By 2016, the government’s own population projections1 predict that Alberta’s seniors population will number half a million people. Studies2 done by the OECD indicate that, in its 34 member countries, an average of 4% of the population over the age of 65 require LTC. By that count, Alberta needs about 20,000 LTC spaces. AHS reports 14,370 LTC beds in 2014, with further reductions projected in AHS’s 2013 Capital Plan. That leaves us with a sizable shortage of about 6,000 LTC beds.

What are the causes of the LTC shortage?

A recent study by the Canadian Institute for Health Information (CIHI) sheds light on these causes. It notes that Alberta’s $4,699 per capita spending on health care is way above the Canadian average of $3,960 (i.e. 18.7% more). However, the percentage of that spending that goes to seniors care (nursing homes and other care facilities) is only 7.5% in Alberta compared to the Canadian average of 10.3%. The $506 per capita spending on seniors care in Alberta compares to the Canadian average of $625 (i.e. 19% less).

To curtail the costs of seniors care compared to its spending on health care, Alberta has used a variety of measures.

Since at least 20084 the government of Alberta has implemented a policy of arbitrarily limiting the number of LTC beds in the province to approximately 14,500. Instead of building the number of LTC beds required, the policy has been to cap the number of LTC spaces and “shift” individuals into Supportive Living settings that are cheaper for the government to operate, but much more expensive for those who require the care and for their families.

Supportive Living covers a wide‐range of accommodation levels ranging from group homes and lodges to seniors’ complexes with varying levels of care. However even at the highest level of care, Supportive Living accommodations are staffed by fewer and less‐qualified staff than required in a LTC facility. In fact, only at the highest level of Supportive Living 4 (SL4) are any regulated health professionals (Licensed Practical Nurses) required to be on site on a 24‐hour basis. The next highest level of Supportive Living 3 (SL3) requires only that “qualified or trained staff,” (i.e. not necessarily a regulated health professional) be on site 24/7.

A second way that the Alberta government has curtailed its costs of seniors care is by contracting the delivery of such care to private operators – both non‐profit or voluntary and for‐profit providers. In these private Supportive or Assisted Living facilities the operator can charge for ‘enhanced’ or ‘supplemental’ services not covered by home care. These can include unregulated charges for care services such as assistance with bathing, escorting to and from dining room, night checks, incontinence management, support stockings and the cost of administering medications, all of which would be covered in a LTC facility.

Despite a 2012 election promise of an additional 1,000 Long‐Term Care spaces per year for the next five years, the current government has failed to increase the number of LTC beds and has continued to increase the number of Supportive Living spaces, which do not provide the care required by those with complex and unpredictable medical needs. 

What are the unnecessary costs of the current situation?

• The government’s effort to curtail expenditures of public money on seniors care has had many largely hidden costs.
• The huge and unnecessary cost to taxpayers of $1,200 to $1,500 a day to accommodate those waiting in acute care beds for LTC placement.
• The undermining of the health care system when as many as 20% to 30%5 of acute care beds in some hospitals are occupied by patients awaiting LTC placement.
• The lack of staff in supportive living facilities who are trained to anticipate and identify potential health issues means that many are transferred to emergency rooms and, from there, to acute care hospital beds for treatment of conditions that could have been taken care of, in‐house, in properly staffed LTC facilities. Some care settings have even used public hospitals as a way of evicting patients whom they decline to accept back after being sent to the ER because their care needs have become too high.
• The government’s active encouragement of partnerships in the construction and operation of nursing homes and supportive living accommodations has resulted in a significant increase in private, for‐profit delivery of care. Such facilities need to generate a return for shareholders which can result in under‐staffing, inadequate pay and training for staff, and a deterioration in quality of care. 2
• The increase in off‐loading of physical, financial and emotional costs of care to individuals and their families, at times resulting in patients’ having to forego necessary care, thereby exacerbating their illness.

What needs to be done to fix the shortage of LTC beds?

To address the chronic shortage of LTC beds, the government needs to stop imposing arbitrary limits on the number of LTC spaces in Alberta and focus on adequately addressing the often complex and changing medical needs of our frail and elderly.

This may require the government to build and staff, on its own or in partnership with community groups, a sufficient number of publicly operated LTC beds to eliminate the current backlog.

LTC beds can be publicly built, staffed, and operated at a fraction of the cost of acute care hospital beds that we now rely on to accommodate patients awaiting LTC placement.

There is a better way?

For many years now, ill‐considered policies have taken us down the wrong road. Rather than trying to avoid the reality that the percentage of seniors in the population will double over the next 20 years, the government needs to confront the problem proactively and stop trying to pass it off to the private sector to solve.

The government defines LTC as care offered in Nursing Homes and Auxiliary Hospitals. But surely, the essential element of LTC is not the venue in which it is offered but rather the high level of medical and care services provided. Consequently, there is no reason why these LTC services cannot be offered in smaller, patient‐centered facilities, with much greater community engagement and local autonomy. As documented in OECD studies6, some Nordic countries have developed a different method of delivery. Long‐term care is funded, regulated and overseen nationally, but delivery is the responsibility of regional and local governments.

Yes, we can do it and we must!

Canadians are justly proud of their health care system. It is intended to provide care on the basis of need, not ability to pay. It treats not only our major health crises but also our sports injuries and the consequences of obesity or addiction, all at public expense. Are we not, therefore, also capable of providing the people who helped build that system with the care they require when they have suffered the adverse effects of aging?

There have been many calls lately for a national strategy on seniors care, including a recent call from the Canadian Medical Association. A major step in that direction would be to include LTC as a covered expense under the Canada Health Act.

What needs to be done!

1. Implement an effective home care and drug coverage system focused on preventing the deterioration of seniors’ health to minimize the need for LTC.7
2. Build and operate sufficient LTC beds to eliminate the current backlog.
3. Provide access to medications, goods and services in all Supportive Living facilities on the same basis as in LTC facilities.
4. Increase funding to implement LTC professional nursing and therapeutic staffing standards either in the form of minimum patient/staff ratios, or in providing 4 direct care hours (not paid hours) of care per resident per day8, with at least 25% of that care provided by RNs. 3
5. Use the Patient/Care‐Based Funding Model9 as a way of determining what allocation is required to meet actual LTC needs, rather than a way of dividing up an allocation arbitrarily determined on the basis of ‘Weighted Resident Days’.
6. Implement regular, unannounced inspection to ensure compliance with high standards of care and safety.
7. Make public all contracts entered into with private operators (either non‐profit or for‐profit).
8. Continue to regulate the cost of accommodation to ensure affordability and uphold the principle of universality of care.

Furthermore, all care settings receiving any form of public funding (either capital grants or operating funding) should be required to:

• Establish meaningful Patient/Family Councils that have authority to address complaints and to refer unresolved difficulties to a Seniors or Health Advocate who is an officer of the legislature.
• Have effective fire and evacuation provisions (both structural and staffing) as a condition of licensing in all care facilities.

Footnotes

1. Alberta Treasury Board and Finance “Population Projection Alberta 2014‐2041”‐ Highlights, P 5 of 7.
2. 2. Country Notes. A Good Life in Old Age. Monitoring and Improving Quality in LTC. OECD Publishing 2013.
3. CIHI, National Health Expenditure Trends, 1975 to 2014 Tables 5 and 6.
4. Alberta Health and Wellness Continuing Care Strategy, 2008.
5. Dr. Parks: Our health‐care system is on verge of collapse”, Calgary Herald 10/5/2014.
6. OECD Ibid.
7. See PIA Home Care and Pharmacare Position Papers <http://pialberta.org/action‐areas/seniors>
8. Zhang, Unruh et al, “Minimum Nurse Staffing Ratios in Nursing Homes”. Nurs Econ, 2006.
9. J M Sutherland et al, “The AHS Patient/Care‐Based Model for LTC; A review and Analysis.” p 8.

Prepared by: PIA Seniors Task Force December 15, 2014

Purpose

The purpose of any pharmacare plan should be to maximize the health of all citizens through the appropriate and safe provision of medications. The effectiveness of any pharmcare plan should be assessed by the extent to which it achieves this purpose through a transparent system of accountability.

Scope

Ultimately, a pharmacare plan should cover all appropriate pharmaceuticals prescribed by doctor or other approved prescriber.

Organization

While most Canadians would fight any government effort to dismantle Medicare, few realize that, of all the developed countries with universal, single-payer health systems, Canada is the only one that does not include coverage for prescription drugs.

Other countries have found it both more economical and more efficient to operate their own, singlepayer, pharmacare programs as an integrated part of their health care system. When government is the major buyer of prescription drugs, it has more influence in setting prices, thereby reducing the cost of pharmaceuticals. It also gives patients access to medications that they can afford to take as prescribed, thereby reducing hospitalizations and the burden they place on the health care system. Canadians pay about 30% more for prescription drugs than the average in the OECD (Organization for Economic Co-operation and Development) countries, and an economic analysis shows that the rational implementation of universal pharmacare, with first dollar coverage for all prescription drugs, would not only make access to medicines more equitable in Canada and improve health outcomes, but also generate savings for all Canadians of up to $10.7 billion in prescription drugs.2 Like health care itself, such

Like health care itself, such pharmacare plans in other countries are usually funded primarily out of general government revenue generated from progressive taxation, with only moderate co-payments from patients who can afford them.

The need for universal, single-payer, pharmacare becomes clearer as our current fragmented system comes under pressure from the growing percentage of our population that is comprised of seniors. In Canada, 80% of prescription drugs are taken by 20% of the general population3, and many of that 20% are seniors who rely on medications to treat chronic conditions, maintain their independence, and mitigate the challenges of aging.

Governments’ response to this population bulge is to abandon drug plans based on age and move to means-tested, income-based plans, a form of charity that is totally inconsistent with the principles of the Canada Health Act. But ignoring the problem of seniors drug needs doesn’t make it go away. This is clearly the wrong way to address the sustainability of our current system. The system needs to be changed by integrating prescription drug coverage into our existing health care system.

The First Minister’s Meeting in 2004 promised a 10-year plan that included a National Pharmaceutical Strategy. However, Canada is still limited to a venue-based plan that only provides some medications to patients in hospitals and in publicly funded nursing homes.

The provinces, being responsible for the delivery of most health care, rely on a messy combination of government plans that cover select groups based on a variety of factors, including age, financial status or particular health conditions. Otherwise, we rely on private insurance plans operated by or for employment groups, or on individual or group private insurance plans, or on paying out-of-pocket, or, as a last resort, on simply going without required medications.

Currently, the provinces use a variety of ways to partially fund whatever coverage is provided for prescription drugs. These plans involve deductibles, co-payments and in some cases premiums, all of which penalize people for being sick and dissuade them from accessing the medications they require.

It also seriously inhibits the health system’s ability to select the most appropriate therapies and control the prices we all pay for pharmaceuticals.

Because this fragmented system involves such high costs for administration, marketing and regulation; and because it wipes out the bargaining power that other countries and jurisdictions enjoy in purchasing pharmaceuticals, it costs Canadians much more than a universal, single-payer system and leaves many of us without coverage.

Another major shortcoming of our current system is the additional and un-necessary burden on our health care system because so many people cannot afford the cost of medications needed to keep them healthy or manage chronic conditions. This problem is compounded by the lack of access to costly new medications.

Pharmaceuticals are a crucial and integral part of health care and, if we believe in the core principle of Canada’s health care system -- that health care should be provided on the basis of need rather than on ability to pay –- then the provision of prescription drugs should be an integral part of our health care system.

It is worth noting, however, that Medicare did not start on a national basis in Canada, but rather as a provincial initiative that eventually grew into a national system. Accordingly, one or more provinces may have to lead the way and we call on all provincial governments, but particularly the Government of Alberta, to work at integrating the provision of prescription medications to all citizens into our Medicare system.

References

1 Steven Morgan et al, Rethinking Pharmacare in Canada, C.D.Howe Institute (No. 384, p. 1)

2 Marc-Andre Gagnon and Guillaume Hebert, The economic Case for Universal Pharmacare, (CCPA, 2010, p. 5 - 11).

3 Morgan, op. cit., p.13.

Prepared by:

Seniors Task Force
Public Interest Alberta
September, 2013

Download the position paper

In developing this position paper, the Seniors Task Force of Public Interest Alberta describes what we think a satisfactory Home Care program should look like. Some of what we advocate is similar to the Home Care program that Alberta Health Services claims to be offering; unfortunately, that offering is not being delivered in anything like a consistent manner in Alberta and its scope and effectiveness is not being properly evaluated.

The purpose of this paper is to outline the scope and essential elements of an effective and economically viable Home Care system that enables frail seniors and the disabled to remain in their own homes as long as possible, thereby reducing the need for institutional care and relieving the pressure on the health care system, particularly emergency rooms and acute care hospital beds. The opportunity to maximize their independence by staying in their homes was recognized in the Alberta government’s Continuing Care Strategy and is clearly what most seniors prefer.

An effective Home Care system needs to be community based and a fully integrated part of the whole health care system so that all care providers know the latest assessed and diagnosed needs of the patient they are serving and what other services have been and are scheduled to be provided by other care providers. Corporate delivery is incompatible with this model.

Scope

To the extent economically feasible, an effective Home Care system has to provide the comprehensive services necessary to ensure the optimum level of physical and mental health of those whom it serves in both urban and rural areas. These services include:

• All medical, paramedical, nursing and personal care services necessary to keep the patient safe and well in their own home.
• Day programs and companionship to support socialization.
• Therapeutic services including mental health counseling and referrals.
• Post-operative and rehabilitative care.
• Wellbeing counseling.
• Respite care where the family is involved in
• Palliative care.

Additionally, an effective Home Care System should provide those domestic and other outreach services not provided by community services, such as:

• Transportation for health related appointments and other necessities.
• Home cleaning, laundry and home upkeep.
• Assistance with shopping and meal preparation.
• Snow removal and yard maintenance.

Quality of Care

A key element in the quality of Home Care is the existence of a sufficient number of care workers with the communication skills and training required, and that those workers are adequately compensated to ensure there is a high degree of continuity in the care provided. The delivery of quality Home Care requires that:

• There is adequate screening of all potential care workers to ensure that they have the aptitude and communication skills necessary.
• There is a progressive series of training programs establishing the qualification of all workers so that those qualifications can be matched to the assessed and anticipated care needs of individual patients.
• There is a compensation scheme that recognizes levels of training, covers all time and travel required to perform the work, and encourages further training, thereby establishing home care as a valued occupation.

A second key element in the quality of care is the establishment of standards of care and the monitoring of those standards to provide for the following:

• Annual or more frequent re-assessment of patient care needs with the establishment of specific and realistic goals for improvement of health.
• A formal appeal process for contested assessments of patient needs.
• Development of procedures for assessing progress in the attainment of health goals.
• Periodic audits of the quantity and quality of care provided by the recipients of care (patient and family or their authorized decision makers).
• A monitoring process that records and reports all adverse incidents with public access to those reports, while protecting the privacy of patients.

Case Management of Home Care

Direct responsibility for the management of effective Home Care should be in the hands of Case Managers who are employed by Alberta Health Services and who have reasonable caseloads. Case Managers should have direct authority to supervise the work of all Home Care workers delivering services to patients in their care, whether the workers are employed by a public, voluntary or private-for-profit agencies, and to require appropriate training or the replacement of workers not providing satisfactory care (following the process in a collective agreement). Case Managers should also have the authority to determine and implement the level of care that is required.

The roles and responsibilities of Case Managers should include the following:

• Monitoring the work of, and maintaining good communications with the Home Care workers assigned to patients in their care.
• Ensuring that materials and equipment are in place to secure the safety of the patient and a safe working environment for the care providers.
• Ensuring that all changes in the condition or needs of patients in their care are brought to their attention.
• The responsibility for calling other health care providers to provide services, when necessary.
• Liaising with hospitals, PCNs, FCCs, physicians, nurses, LPNs, physiotherapists, pharmacists and social workers involved with the patients in their care.
• Keeping Home Care workers and the families or their authorized decision makers fully informed of changing circumstances of patients in their care.
• Keeping the patient and family fully involved in decision-making and informed of all services available from AHS and the community.

Administration and delivery of Home Care

Home Care must be a comprehensive and fully integrated service that is universally available on the basis of assessed needs. The delivery of Home Care services should be administered on a community-based model involving Family and Community Social Services, municipal organizations, cooperatives and other community organizations to ensure continuity and transparency, in accordance with provincially set standards.

All agencies providing Home Care should be regulated and, where publicly-funded services are provided under contract, those contracts shall be fully transparent.

Funding of Home Care

The cost of Home Care delivery should be borne by government to the extent required to ensure that all health care services are provided without charge to the patient.

Download the position paper.

Visit the Seniors Task Force page.