Category Archives: CCAC

“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.

Should the LHINs really be the e-Harmony of health care providers?

When the province decided to call its most recent crown agencies Local Health Integration Networks, it was clear where the emphasis lay.

Rather than plan a system based on need, it appears the primary function of the LHIN was to ‘integrate’ health services.

Integration can be broadly interpreted – it doesn’t necessarily mean mergers of health providers, although it can be. It can also mean greater cooperation and collaboration between providers, or transfers or even swaps of services from one entity to another. Under the Act’s definition, integration can also be the winding up or closure of a service – something most of us would not see under the normal dictionary interpretation of ‘integration.’ The extension of that illogical concept is that by blowing up the entire health system you’d have full integration.

It seems the province was short a philosopher when they needed one.

The province maintains that about 250 integrations have taken place since the LHINs came into effect in 2006 – most being of more recent vintage. That surprises us given much of the system seems to be still dipping a toe into the integration pool.

Some integrations happen by default. Sometimes a small agency just decides it can’t continue any more and the LHIN is left scrambling to transfer the work to another health provider. Perram House hospice, for example, gave the Toronto Central LHIN just a couple of weeks notice to say they were calling it quits.

Just because a service transfers from point A to point B, doesn’t mean that the system as a whole becomes any more fluid or patient-centered. Sometimes it makes it worse.

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Home care safety report at odds with new directions at OACCAC

By now every Ontarian has heard how hospitals are unsafe. Patients are told the shorter the stay, the less risk, in order the help them understand the need to vacate their bed long before they feel physically able to go home.

The problem is there has been very little study to determine risk in alternative settings, including home care. Just because a hospital stay poses risks, it doesn’t mean home care or other settings are necessarily safe.

This summer the Canadian Patient Safety Institute released its first pan-Canadian home care safety study.

If anything, the report underlines the difficulty in even assessing risk in this environment, pulling data from multiple sources – not all of it consistent from province to province. The authors note that home care safety issues are only beginning to be addressed in healthcare literature.

Depending on where the data is drawn from, annual rates of adverse incidents can vary from 4.2 to 13 per cent of Canadians receiving public home care.

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De-integrating home support services in Ontario

Ontario has promised three million new hours of home care personal support services over the next three years. While it sounds like a lot, keep in mind that about 32 million hours of public home care are delivered annually and another 20 million hours are paid for privately. Further, the province is leaning heavily on the sector to offload clients from Ontario’s hospitals. The province tells us that the new hours will assist 90,000 more seniors, or 30,000 more per year. In 2011/12 a total 637,727 clients were served by home care according to the Ontario Home Care Association.

Last year the province introduced a PSW Registry (Personal Support Worker), which sets qualification standards for these workers in order to be on the registry. Without the bother of creating a specific professional college for these workers, the registry was supposed to be a way of maintaining discipline among a group that is generally ill defined and whose duties can vary dramatically.

Just before the December holidays, the province quietly introduced regulatory changes to expand which agencies can provide PSWs to do this work.

The change in policy allows community support service agencies (CSS) to deliver personal support services, but will not require the PSWs hired by these agencies to be on the new registry – at least not yet.

These support agencies have traditionally carried out functions such as delivering meals on wheels, carrying out homemaking duties, running social day programs, and providing transportation services to the frail and elderly. While such services can include respite care, they are generally not the kind of agencies that would provide a bath or assistance with toileting or dressing, for example.

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Smiths Falls and Perth communities tackle deep hospital cuts

Two community meetings around cuts to the Perth and Smiths Falls District Hospital drew significant crowds this week.

Cuts at the two-site rural hospital corporation are particularly severe. The Perth and Smiths Falls District Hospital is seeking to find 6 per cent in savings primarily through reductions to health resources used by the community, including a cut of 12 beds, six at each site.

This is only the beginning given every hospital is struggling with zero-based budgeting from the province that is expected to impact the bottom line to 2016-17. The situation is made worse at hospitals like Perth and Smiths Falls due to the simultaneous implementation of a new funding formula that doesn’t appear to appreciate the unique demographic demands of the region.

The Health Minister and local opposition MPP Randy Hillier say services are not being cut, but are being reallocated. But is this really true?

The cuts include physiotherapy where the equivalent of more than three full-time positions will be lost at the hospital.

Numerous provincial reports have acknowledged that seniors are having trouble connecting with publicly funded physiotherapy.

Last week it was the turn of Dr. Samir Sinha, the provincial lead on Ontario’s Seniors Strategy. Sinha called for more publicly funded physiotherapy in the community, but the last OHIP-licensed private physiotherapy clinic to open in Ontario was in 1964. Health Minister Deb Matthews has been silent on this issue despite cuts to physiotherapy in about half of Ontario’s hospitals during the past year. This is one more.

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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.

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Nursing home placement — Who has the greater crisis?

Yesterday we looked at the challenge of CCACs is managing scarcity amid too few available nursing home beds in the province.

One of the ways of placing a client into the nursing home faster – albeit with a three-month median wait – is to declare them a crisis priority.

The Long Term Care Act specifically requires that crisis clients be prioritized on the basis of urgency of need, but the question is whose need?

The Auditor General of Ontario (AG) looked at this issue and revealed there are many ways in which an individual can become a crisis priority, including simply taking up space in a hospital that has itself been declared “in crisis.”

“All patients waiting for a LTC home in this particular hospital are generally given crisis priority,” the AG’s annual report states. In fact, on a four level scale, these patients would rank number one.

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