Living Longer, Living Well: Muddled seniors strategy undermines universality of home care

There have been fewer than the usual suspects applauding the release of Living Longer, Living Well, Dr. Samir Sinha’s anticipated recommendations for a new seniors strategy for Ontario. In the early days of 2013, maybe nobody is yet paying attention.

Appointed provincial lead last year by Health Minister Deb Matthews, Sinha spent much of 2012 travelling the province and consulting with everyone it seems but organized labour (not that we’re bitter).

Promised for December, the subsequent report did not linger long in the Minister’s office before the highlights were released publicly yesterday. The full report is expected in the next few weeks.

Like last January’s provincial strategic plan, Dr. Sinha’s strategy seems to be long on lofty recommendations and somewhat short on logistics about how this all gets done, especially in an environment of considerable restraint.

Depending on where you sit on the political spectrum, you’ll likely find recommendations you like and recommendations that seem completely off the wall.

Regardless, the key recommendation around resources does leave much to be desired, suggesting the province should “at least” continue the present 4 per cent annual increase in spending on home and community care planned for the next three years.

Not all recommendations involve spending by the Ministry of Health, but there are no references to other departments kicking it up a notch.

Given these are not big budget sectors compared to primary care or hospitals, the government could likely afford to be more generous without blowing the bank if it truly believes Sinha has the answers. The underlying theme is that with these additional resources, there could be savings on other points in the health system, although little evidence is offered.

Much has been made of his argument for more long-term care beds – Sinha told the Toronto Star that the numbers need to be tripled over the next 20 years. We should note that the highlights document does not actually make that specific recommendation – instead it speaks more vaguely about funding as resources become available. That could take a long time – just ask Ontario Children’s Advocate Irwin Elman how agencies have been waiting for funding to implement hundreds of inquest recommendations from the Coroner’s office. Given Sinha suggests that these problems are on a clock, the laissez-faire approach to funding seems badly misplaced.

Never-the-less, the CCACs must be cheering given the government’s recent restraint on adding new nursing home bed capacity has left them under considerable pressure. When Dr. Sinha spoke at last November’s OHA conference, one unnamed CCAC executive practically begged him to recommend an increase in nursing home  bed capacity.

More controversial is the recommendation Health Minister Deb Matthews seems much more interested in – making wealthier seniors pay for more of their home care and support services. By wealthy, the province defined those seniors earning more than $100,000 a year individually or $160,000 a year as a couple when it came to implementing a similar “make the rich pay” scheme for the provincial seniors drug plan. That was not a slight rattling of the cup either – the plan to be implemented in August 2014 will take three per cent of the net income of so-called rich seniors earning a combined $160,000 or more per year. How much more would the province be adding to that bill for home care costs?

While “make the rich pay” is a popular mantra these days, most would not necessarily consider these incomes as rich, especially if you are still paying down a mortgage in the City of Toronto. The other problem with such fixed parameters is that inflation can erode these figures well into the core middle class within a relatively short number of years. Just look at the masses of ordinary workers who have been thrust into the similarly unadjusted Sunshine List.

As Derrell Dular, managing director of the Older Canadians Network says, we already have a means-testing system for funding care – it’s called the tax system.

Sinha follows Dr. David Walker’s lead in recommending greater access to physiotherapy for Ontarians over 65, albeit clinic-based and not in the home. Like the “make the rich seniors pay” recommendation, Sinha suggests that enhanced access to clinic-based physiotherapy services should be “especially for those on limited incomes who often forego this therapy when prescribed due to their financial means.”

Given the rapid rate publicly funded physiotherapy is disappearing in Ontario, this is at least something to cling to, although this was not one of the Minister’s talking points yesterday.

Short on specifics for new care models, Sinha instead punts the football downfield to a proposed provincial working group to develop. That group includes geriatricians, care of the elderly family physicians, specialist nurses, allied health professionals, and others. He follows a similar path with regards to an aboriginal seniors strategy.

Coordination of health services has been the buzzword for the last number of years, so it is therefore difficult to understand Sinha’s almost conflicting recommendation that nurse-led outreach teams go into long-term care homes to meet the more complex needs of residents, while “exploring” the idea of having the long term care homes serve as community hubs that could provide “community-oriented services, including home care.” Did the CCACs miss that in their applause for Sinha?

Much of the rest of the recommendations are shop-worn ideas that have been around for years with only mixed success, from transportation and housing support to elder abuse programs and enhanced education programs for front-line providers.

Maybe we need to wait for the long player version of this report, but overall the seniors strategy appears to be a vague muddle with little coherent strategy to make it happen. To read the 21-page highlight document, click here.

20 responses to “Living Longer, Living Well: Muddled seniors strategy undermines universality of home care

  1. Dr Samir Sinha’s report – Living Well, Living Longer is just “another report” for the shelves – money spent on talk that is too far fetched to address the problems in our Health care system as it is today. Dr Sinha addressed a group of Health Care workers by teleconferencing in Sudbury and in November 2012. I was not impressed. I am a Registered Nurse. I have been in the Health Care field for 50 years and worked at all level – front line, supervision and Management. Dr Sinha’s talk was simly that – talk
    Dorothy Klein RN BScN

  2. The full report has not yet been publicly released – I’ve been told within the next 2 weeks.

  3. This is a terrible report. Vague, ‘continue to support’ it says several times. it’s a PR stunt that cost us a bundle.
    /hospice volunteer

  4. The report will be 200 pages long and contain 169 specific recommendations. The above blog is nothing more than anticipatory sour grapes.

    • I agrree. Samir only outlined a proposed plan. I did not see/read any strategy. We have had many many plans for development of Health Care but few comprehensive strategies and even less “buy in”.
      Samir’s report is just another report for the shelves. Talk but no “will” from the people to implement any aspects on a broad basis.
      Dorothy Klein R.N. B.Sc.N.

  5. George its not “anticipatory” when you’ve seen the 169 specific recommendations, of which this commentary is based. Not sure what you mean by sour grapes? Did you actually read this post?

    • I applaud you, and am jealous of you, for implying that you have seen the embargoed recommendations, though not sharing them all on your blog makes it hard for your audience to engage in meaningful debate and consider alternate points of view.

      Being one of those geriatricians who is working very hard to implement those shop-worn ideas (something that has actually never been done correctly or completely, even by the groups in Montreal – please read Vedel et al 2011), and knowing Samir quite well, I am rather more optimistic than you are.

      The notion of LTC homes acting as hubs is actually quite brilliant – imaging a centre where expertise in the management of frail seniors, from those living in the community to those requiring 24 hour care, can be concentrated and act as a knowledge and service repository for the community. We cannot expect all providers to know enough geriatrics, nor can the small number of geriatric physicians and nurses be able to assume all of this care either. The notion of an intermediary level of care is what we are talking about – see Ian Scott’s papers from 2007 and 2008 on chronic disease management.

      But in the meantime, there is very good data to suggest that LTC homes need help – staff in LTC universally endorse that they have insufficient knowledge to deal with increasingly complex seniors, nor do they function in a particularly effective inter-professional manner (see Newhouse et 2012, and Marcella et al 2012). And so, outreach teams are a useful measure in the interim, until we address the underlying knowledge gaps and interprofessional dysfunction with, you guessed it, “enhanced education programs for front-line staff” – that and fixing curricula across the board to improve both the geriatric content and the interprofessional training of new grads in medicine, nursing, PSWs, and allied health.

      The problem is that, so far, there are very few models in the literature which have been shown how to organize this care and improve outcomes, other than adhering to the principles of system integration and implementing them locally using existing resources. However, the barriers to true system integration are substantial and difficult to address, and include some measure of local integration of financial and administrative levers, shared and standardized assessment, and a more proactive, collaborative approach to geriatrics. The current approach, which is to deal with frail seniors after they have suffered from complications, usually triggered by their encounter with a health care system that does not understand or address their needs, is a dismal failure.

      Furthermore, the proposals you critique the most are actually presented in a far more nuanced way. How society is to pay for this is for society to discuss. Samir was pointing to models used elsewhere – not dictating what is to be done. And we will likely require more LTC homes, but with better community resources, we can hopefully curb the need.

      I’d be happy to work with you and everyone else to improve our system – as long as input and feedback are constructive and not “short on specifics” either.

  6. Follow the link and you will see the recommendations. The question is, where is the full report? This summary version came out at the beginning of January. I think you answered your own point about the ability of private for-profit long term care homes to gain the expertise to become hubs. In long term care, the municipal homes are likely to provide more specialized care. But then again, didn’t the province reduce the responsibility of municipalities like Toronto to operate more than one home? No debate the system doesn’t work very well here. You won’t find us arguing for the status quo. Samir was supposed to be working on a strategy, not just telling us how its done elsewhere.

    • Your comment about for-profit homes makes little sense as expert hubs makes no sense.

      The report is at the printers’.

      Try to be more optimistic and guided more by evidence. You’d make a more helpful collaborator!

      😉

      Cheers.

      G

  7. Awesome post. Thank you for sharing! 🙂

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    • This has all been a political ploy. The issues facing senior has not been taken seriously. Seniors are concerned about finances – cost of housing, food etc. They are also concerned about future care. The articles are just retorique
      Dot Klein Sudbury Ontario

      • George Heckman

        Dear Dot: Can you elaborate?

      • Seniors are concerned about the cost of living go up all the time while their income is “capped”. The expenses are essential – housing, heat, lights, food. Adequate housing is essential to health.
        Senoirs are not interested in “group housing” and treated as a “pack”. There is no dignity or respect in that. They want to be recognized as individuals with individual needs. They want to be as independent as possible and to know how to get the help they need.
        We should be develpoing those resources now and making sure they are affordable and accessable to all seniors. That is not happening. The study/report remains at the “talk stage”. There is no plan that can be put into place with commitment
        Dot Klein

  10. Yes, have to chime in, refreshing talk all round in an effort to get dialogue actually working from a number of levels/perspectives.

    On the patient/client health care interventions– Communications Front of daily care throughout the system Front, which is key to care, just wondering if any concrete and on the ground tangible directions to actually getting doc’s and systems to share: tests, intervention strategies in an accessible to all manner?

    I’m with George Heckman with the on the ground everyday, realtime effort to advance practice that builds upward change and find a way to bridge to broader organizational/system initiatives, despite the multiple, occasionally strange, frequently “systemic” barriers in play.

    • There has to be more effort to engage seniors from ALL walks of life and all ages etc. when designing strategies. ONE SIZE DOES NOT FIT ALL. seniors in rural areas and in the north have very different concerns than those in urban and southern areas. Seniors that have affluent pensions have very different concerns than those on limited income/poverty level. Last week I attended a meeting at which the minister for Seniors spoke. I was horrified by his limited knowledge about seniors issues in the north.
      26 % of the population of Sudbury are seniors. and this is increasing. The smaller towns surrounding have a much higher %. These persons MUST be engaged
      Dot Klein

      • George Heckman

        I agree, Dot.

        The strategies outlined in the report are high level. However, they are widely applicable. That said, local implementations must reflect local realities, and engagement MUST include seniors.

        G

  11. I completely agree with Dorothy about a system that is more responsive to the needs and wants of seniors.

    That said, chronic disease happens, as do geriatric syndromes. And the complexity of health problems faced by seniors exceeds the abilities of single individuals, or single professions.

    There are two implications here. “Abilities” are rooted in training. Most practicing providers have grossly inadequate training in the care of complex seniors. This causes seniors to experience accelerated decline, greater use of home care, acute care and ultimately long-term care, and therefore cost.

    The other implication is that providers must collaborate more effectively. I’ve worked with personal care workers whose concerns about residents/patients are dismissed by professional staff. I’ve seen comments from doctors who think that being available to a 200-bed nursing home a half-day every 2 weeks is adequate, and others who admit that they have no idea about the amount of work their orders cause for staff.

    I’ve also seen leaders among PSWs, nurses and physicians who take it upon themselves to collaborate with specialists, and collaborate with each other, and provide superb care.

    We are implementing reforms in many Ontario areas to improve the early assessment and identification of seniors with early frailty in order to intervene early. It is better to prevent Humpty-Dumpty from falling off the wall in the first place, because putting H-D back together again is not easy.

    The task is herculean. There is a lot of inertia rooted in ageism and, in many, the misguided notion that they communicate with others “just fine” and know all the geriatrics that they need (“I MUST be doing a good job because my senior patients don’t complain”).

    But only until we address those systemic barriers will we be able to provide person-centered care and save enough money to afford the living options described by Dot.

    That means more people must complain, but they must do so in a constructive manner. There is a lot of good stuff in the Sinha report. Don’t just sit there on your laptop: get involved!

    😉

    G

    • Thank you very much for this longer reply. Thank you for the encouragment. Communication at all the levels is most important and the key to patient centred care
      Dot Klein

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