“Care as a relationship” is key to good long-term care: research

What are long-term care residences around the world doing right?  That’s the question an international research team travelled across North America and Europe to find out.

Led by Pat Armstrong and Donna Baines, researchers visited nursing homes in Canada, Germany, Norway, Sweden, the United Kingdom and the United States, looking for practices that make long-term care centres feel like home to their residents.

diablogue fotoTheir findings won’t surprise long-term care workers. Good long-term care means building strong care relationships between residents and their care providers. Strong staffing levels, good working conditions, secure jobs, proper levels of public funding, full-service kitchens with in-house food service staff, and sensible standards – not onerous bureaucratic one-size-fits-all rules – lead to excellent care for residents.

The research by Armstrong and Baines resulted in a highly-readable, information-packed book called Promising Practices in Long-term Care: Ideas Worth Sharing (2015). A collection of short and moving vignettes from 13 long-term care homes is accompanied by solid statistics and eight recommendations for promoting care as a relationship. (Download it free here.)

Removing private profit leads to better care

The researchers found that non-profit nursing homes with adequate public funding were more likely to have better working conditions.  The links between good working conditions and strong care relationships with residents are obvious:

  • Adequate staffing levels ensure that staff have time to interact with residents;
  • Permanent, secure jobs with stable work schedules help residents get to know regular staff who care for them at predictable times;
  • Paid sick leave allows staff to rest when sick and avoid infecting residents at work;
  • Good wages, hours of work, benefits and pensions reduce staff turnover, which ensures continuity of care;
  • De-emphasizing excessive paperwork and charting allows staff more time to interact and socialize with residents;
  • Offering staff continuing education increases their ability to provide quality care for residents;
  • Having all services provided by in-house staff instead of contracting it out (e.g. food service, cleaning and laundry) results in better quality and more personalized care for residents.

These findings are in line with a recently-published study by the Journal of Post-Acute and Long-Term Care Medicine showing that for-profit nursing homes in Ontario have 16 per cent higher death rates and 33 per cent higher hospitalization rates than non-profit facilities.  For-profit homes also have higher rates of falls, incontinence, and use of restraints.

Focus on good food

The way to our hearts may not be solely through our stomachs, but good food makes a big difference to quality of care, Armstrong and Baines found.  Many of the promising practices in their book revolve around food.

Time and again, they found that long-term care residences where all meals are prepared, cooked and served onsite by their own staff provided much better meals, and better overall care for residents, than those who contract out food services.

When food is cooked onsite, residents can smell it cooking. It stimulates their appetites and makes them look forward to meals. Directly-employed food service staff get to know individual residents’ likes and dislikes. They interact with residents at meal and snack times, creating another continuous care relationship.

When food service is contracted out, strict meal times must be observed because contractors enter and leave at set times. But when in-house food service staff have food available all day long, or even 24 hours per day as it was in one residence in the book, there is no pressure for all residents to eat at exactly the same time.

This takes a lot of pressure off of other care staff as well. Care relationships are built through conversations and exchanges during and in between routine care tasks. In homes with flexible meal times, personal support workers don’t have to rush through care routines to get residents to the table by a set time.  That leaves time for relationship and trust-building.

In a care home in Germany, residents were even encouraged to help with the food preparation as they were able, with food service and personal care staff nearby to assist when needed.  This created a social atmosphere between residents and care staff, and fostered residents’ independence.  In a residence where food preparation and service is contracted out to private companies, this kind of interaction doesn’t have a chance to happen.

Time to care: Relationships over bureaucracy

Decreasing staffing levels lead to lower quality care, which then leads to bureaucratic rules requiring excessive documentation and the regulation of what should be common sense.

Personal support workers in Ontario often have to do well over an hour of routine charting every day – time they could spend assisting and interacting with residents.  In contrast to this, one Manitoba nursing home visited by the research team “charts by exception” – in other words, they only document occurrences that are out of the ordinary or things they specifically need to track.  This gives them time to build care relationships with residents.

In the nursing homes visited in Germany and Sweden, there was a greater focus on putting “more life into days than extending the days of life.”  A certain level of risk is accepted in exchange for quality of life.  Residents engage in activities that encourage independence, like food preparation using knives, or walking about instead of being pushed in wheelchairs. Residents with dementia who wander are watched and redirected by staff instead of being restrained or locked in. Staff have time to sit and talk with residents, meeting their socialization needs, not just their personal care needs.

But these practices require a high ratio of staff to residents.  The German nursing home above had staff to resident ratios as high as 1:3. In Ontario, there are no regulations for minimum staffing levels to ensure that other regulations are met, such as the provision of toileting assistance, repositioning, and other types of assistance.  Some Ontario PSWs are responsible for up to 42 residents at a time.

Good care also requires more staff time per resident. On average, residents in long-term care homes in Ontario currently receive the following:

This is well below the four hours of direct care per day that the Ontario Association of Non-Profit Homes and Services for Seniors recommends.

According to Armstrong and Baines, high quality long-term care could be the norm instead of the exception in Canada, if we had the desire and political will to make it happen. It will require a culture shift – a move from thinking of care for seniors in terms of a business model, to thinking about what long-term care residents need in order to live fulfilling, dignified lives.

Relationship-building cannot be legislated.  But we can create the conditions under which care relationships can thrive by setting minimum staff ratios and care hours per resident, creating better working conditions for staff, committing to strong public funding and removing the profit motive from long-term care.

OPSEU fights back against Wynne’s hospital cuts

OPSEU is ratcheting up the campaign against the Wynne government’s relentless attacks on Ontario’s health care system.  Here’s what’s happening across the province:

  • This week, the Ontario Health Coalition is rallying daily outside the pre-budget consultations being held throughout Ontario. Find out where and when the rallies are happening here. Join them!
  • This morning, OPSEU’s Hospital Professionals Division is launching a radio ad campaign to promote its new website PublicIsBetter.ca. Listen to the ad. Share it with your friends.
  • The campaign is being promoted on newspaper websites and Facebook.
  • A punchy online video shows the impact of health care funding cuts and how Wynne can start undoing the damage.

sad_hospitalThe goal is to put restoring our health care system on the Wynne government’s agenda.  Our treasured public health care system is suffering death by a thousand cuts. And it is happening with no public mandate.

For example, in 2014 Ontario brought in regulations making it easier to outsource community hospital services to private, for-profit clinics. These clinics typically take on low-risk, high-profit procedures such as cataract and colonoscopy services. This sucks money away from public hospitals.

Prior to the federal election, federal Liberal leader Justin Trudeau said that “some of our greatest achievements as a country – the things that matter in the daily lives of Canadians – came about when federal, provincial, and territorial governments worked together to forge solutions to complex problems.  One example that touches all Canadian, in a profound and personal way, is medicare.”

He also said that “our health care system isn’t perfect, but it represents the best of Canadian federalism. It’s flexible enough to respond to the different regional needs, while protecting the national principles Canadians hold dear.”

It’s time for that flexibility to kick in.  A good start would be for our premier to say to the prime minister that Ontario desperately needs federal financial assistance to rebuild a once-proud health care system in this province.

But Trudeau knows the Wynne government has only itself to blame for its supposed financial difficulties. Corporations in Ontario have enjoyed a windfall of tax cuts that started with the Harris Conservative government and continued under the Liberals.

These and other cuts are costing the provincial treasury $20 billion a year. So it may ring a little hollow when Wynne says to Trudeau that she needs help because the Ontario cupboard is bare.

Still, Trudeau must help rebuild Ontario’s once-cherished public health care system, and help other provinces as well.  But Wynne could make Ontario’s request more attractive by showing she is willing to do her part.  She should use her legislative majority to restore the corporate tax rate to earlier levels.  That would raise more than $2 billion a year right away.

Later this week the federal/provincial/territorial Health Ministers meet in Vancouver.  It would great if our Health Minister, Eric Hoskins, could truthfully tell his colleagues that Ontario is committed to restoring a strong public health care system.

Home care: the debate the government wants to avoid

Ontario’s malfunctioning home and community care system is a prime example of why private sector companies should not deliver health care. They don’t do as good a job as the public sector.  And the private sector is more costly.

The home and community system’s problems are so severe that Health and Long-Term Care Minister Eric Hoskins recently announced that the province’s 14 top-heavy Community Care Access Centres were being shut down.  Local Health Integration Networks will expand and absorb the CCACs’ responsibilities.

In making the announcement, Hoskins summed up what we have been telling the government for years:  “Too often, health care services can be fragmented, uncoordinated and unevenly distributed across the province. For patients, that means they may have difficulty navigating the system or that not all Ontarians have equitable access to services. Too often our system is not delivering the right kind of care to patients who need it most.”

The minister released a discussion paper asking Ontarians to tell the government how home and community care could be improved.

But perhaps the process should be reversed.  Perhaps the public should release a discussion paper and ask the government to respond.

Who made the decision to privatize Ontario health care by stealth? In what election did Ontarians vote for privatized health care?  When did Ontarians vote that our health care system’s primary goal be profit?

The government wants more treatment traditionally provided in hospitals relocated to the home.  This includes vital services such as dialysis, complex wound care and palliative services.

There are often good reasons for doing this.  Many patients recover more quickly after surgery if they rest at home rather than in the hospital.  And it costs less.

But as more health care services are transferred from the hospital to the home, the Wynne government is quietly transferring care delivery from the public to the private sector.  It is laying off workers in hospitals and contracting private companies to provide home and community care services.

But for-profit health care companies strive to make as much profit as possible.  That’s why they exist.

Ontario’s Auditor General recently looked at the level of care offered by home care providers that are under contract to Community Care Access Centres.  She found that only 61 cents of every dollar paid by the CCACs actually ends up going to face-to-face patient care.

What happens to the rest of the money?  The 39 cents per dollar?  Much of it goes to managerial salaries and profits of the for-profit companies.

These companies maximize profits by pushing down wages and forcing their workers to rush through their treatments.  For many, their mantra is “cheap and fast.”

But cheap and fast should not be the guiding principle of a health care system.  The guiding principle should be to do what is best for the patient.  This is the principle followed when care providers work for the government instead of the for-profit companies.

This should be the focus of public debate. But not surprisingly, Hoskins’ discussion paper doesn’t ask for comment on its privatization agenda. Privatization is a conversation the government desperately wants to avoid, because the facts show that privatization results in poorer patient care.

Where’s Linda Knight now?

OPSEU Information picket outside the Niagara CCAC offices March 19th.

OPSEU Information picket outside the Niagara CCAC offices March 19th.

When the unhappy staff at the Niagara branch of CarePartners first entertained the idea of organizing themselves into a union, CarePartners owner Linda Knight picked up the phone and called each of the workers. She promised that things would get better if only the front line home care workers gave her another chance before joining a union.

Nobody knows any of the financial details of Knight’s business – the for-profit CarePartners is not publicly traded and is therefore not required to report the details of its operations. Nor are for-profit companies working with public money required to post on the Sunshine list. We do know that in 2003 Profit magazine ranked Knight 33rd among the top 100 women business owners based on the firm’s gross revenues. Media reports suggest CarePartners had more than 500 nurses on the payroll – a huge leap forward from the kitchen-table nursing operation Knight started in 1984.

The fact that a prominent CEO and business owner would call about 100 workers pleading with them not to organize was extraordinary.

The gambit worked at the time, and the workers gave her another chance to make things better.

Knight never honoured that pledge.

Fool me once, but not twice.

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ONA Strike: Home Care critical to Ontario’s health care strategy – just tell that to the CCACs

Picture of OPSEU President Warren Smokey Thomas with striking ONA CCAC professionals in Kingston on Friday January 30.

OPSEU President Warren (Smokey) Thomas (far right) with striking ONA CCAC professionals in Kingston last Friday.

About 3,000 professional staff at nine of the 14 Ontario Community Care Access Centres started walking a picket line Friday.

Represented by the Ontario Nurses’ Association, it’s the latest labour disruption in a sector the government considers to be critical to its overall health strategy.

About 140 OPSEU home care workers at ParaMed Home Health Care in Renfrew withheld their services last September after their agency initially failed to negotiate a deal that would lift many of its workers out of poverty. In 2013 SEIU took 4,500 personal support workers at Red Cross Care Partners out on strike over similar conditions. Following that strike the government implemented a well-intentioned but poorly constructed initiative to stabilize the Personal Support Worker (PSW) workforce by increasing funding for their wages over three years. As the government passed on wage increases for these PSWs, some private for-profit home care agencies clawed back compensation for travel time and mileage. In Niagara and Norfolk Counties OPSEU’s nursing staff at CarePartners are likely to strike soon to gain a first contract.

Health Minister Dr. Eric Hoskins has appointed former RNAO President Gail Donner to lead an expert review on the sector. Her recommendations are expected early this year. They can’t come soon enough.

The pressures during this latest strike will be tremendous given Ontario’s underfunded hospitals have little room to maneuver now that the ability to discharge home care patients to the CCAC has become much more limited.

The CCAC boards are looking particularly ridiculous. The Toronto Star reports that ONA was asking for a 1.4 per cent hike for its workers after emerging from a two-year wage freeze. To most people, that seems more than reasonable in the face of the lavish wage increases the CCAC boards have been bestowing on their CEOs.

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Deep River faces Ontario’s plan for laboratory testing: pay more, get less

Photograph of medical laboratory staff at London Health Sciences.

OPSEU Medical laboratory staff at London Health Sciences. Ontario hospitals are closing their doors to outpatient testing due to funding prohibitions, yet outpatient testing could save money and make labs more efficient.

One of the last hospitals in Ontario to provide local outpatient medical laboratory testing is transferring the service to the private for-profit Lifelabs Medical Laboratory Services.

The move will save the Deep River and District Hospital money, but cost the province more and lengthen the wait for results. Its Ontario’s pay more and get less plan.

Patients will still come to the hospital to get their blood drawn and other specimens collected, but the testing will not stay in the Deep River community unless the referring doctor or nurse practitioner marks it urgent (STAT). All existing inpatient testing will remain at the hospital’s lab, which is part of the amalgamated Eastern Ontario Regional Laboratory Association (EORLA).

Coincidentally the move comes as the hospital is expanding to consolidate physician offices on site. As the physicians come closer into the central health hub for the community, the lab testing will be conducted further from Deep River.

EORLA and Deep River and District Hospital will still have to maintain staff and laboratory facilities that could easily handle these newly outsourced and privatized tests. Deep River must have staff present 24/7 to provide inpatient and emergency testing. Instead of turning around tests “super fast” at the hospital, professional laboratory technologists, technicians and phlebotomists will have much less to do. About 70 per cent of the hospital’s present lab work is conducted for outpatients.

Each outpatient test performed by Lifelabs is paid for publicly by OHIP. While the hospitals could perform these tests for much less using surplus capacity, they are prohibited from similarly billing OHIP. Instead they are expected to provide this service out of an annual budget that has been shrinking in relation to its overall costs.

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Hospital Cuts: Barrett could be hero or goat depending on the future of Chesley’s Restorative Care Unit

There was standing room only in Elmwood last Friday as residents rallied to save the Restorative Care Unit at the Chesley hospital.

There was standing room only in Elmwood last Friday as residents rallied to save the Restorative Care Unit at the Chesley hospital.

Michael Barrett has a problem.

The CEO of the South West Local Health Integration Network (SW LHIN) now has the ball in his court as local support has been building to save the restorative care unit at the Chesley Hospital, one of four small sites that make up the South Grey Bruce Health Centre (SGBHC).

Barrett’s LHIN initially funded the 10-bed unit on a trial basis three years ago. The problem is the LHIN had no plan in place should the trial turn out to be a runaway success. There was no funding for year two or beyond. That would be the hospital’s problem.

This may not be as odd as it sounds. The LHINs frequently incubate new projects through one-time funding. Some don’t pan out. Others do. In normal circumstances, new money is often found to keep the successful high-performing programs going, but these are far from normal times.

The restorative care unit at Chesley was successful and everybody knew it. When the hospital announced it didn’t have $800,000 to keep the program running past the end of April, the community quickly rallied. The media were filled with testimonies of how the lives of patients were turned around with a few weeks of restorative care at the hospital.

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