Category Archives: Home Care

“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.

Tory health platform review: Direct promise to scrap LHINs, CCACs missing

Diablogue Election Primer graphicCuriously after months of saying they’ll do away with both the Local Health Integration Networks and the Community Care Access Centres, both direct promises are conspicuously absent from the formal Tory election platform. That doesn’t mean they will stay in place either.

They do say they’ll instead place decision-making in the hands of “health hubs,” which will bring together “front line local experts from every aspect of health care together at the same table.” Elsewhere they define these local experts as “front-line professionals.”

“We think your nurses, doctors, community care organizations and hospitals know best what care you need,” the platform document states.

So what’s a health hub? Previously the Tories had described these not as some kind of broad-based panel of front line health professionals, but instead 30-40 large central hospitals which would run the health system within their sub-region.

The Tories may be massaging that pledge given it would strike at the independence of mostly local rural hospitals — which is where much of their electoral base resides. The first round of hospital consolidation under the Harris government created a lot of friction as smaller community hospitals found many of their services consolidated in larger urban sites. If the “health hubs” idea is to be implemented according to their earlier “white paper” it may be a vote loser in many smaller communities across the province. Nobody wants to see their hospital services taken away.

The platform is remarkably vague on how these “health hubs” would now be constituted. Watch for a possible name change, some new signs and a coat of paint applied to the Local Health Integration Networks.

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What took so long for community funding to arrive?

Community health care received the biggest percentage increase from this spring’s provincial budget, signalling the government’s intention to transition more of the health system into home care and other community supports.

At four per cent clearly that transition is not going to be at an overwhelming speed, the money barely enough to cover inflation, population growth and the impact of an aging population. However, compared to the base funding freeze for hospitals, this looked like one sector that at least wouldn’t be scaling back health services this year.

For much of 2012 many home care watchers were wondering if and when the money would actually arrive in the sector. Finally in recent weeks there has been a series of announcements around new funding to Community Care Access Centres (CCAC) and other community-based services agencies.

The funding will extend beyond traditional home care. The Central East LHIN, for example, has allocated $9 million in funding to the CCAC, but there is more than $2.6 million more going to other recipients, including new and expanding adult day programs in Whitby and Peterborough, increased hours for the Nurse Practitioner clinic at the Port Hope Community Centre, expanding advanced addiction and concurrent disorders treatment capacity in Scarborough and Durham, more services for individuals living with acquired brain injury and increases in assisted living for a number of communities. The November 14th CE LHIN press release noted that $1.08 million was still not earmarked.

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CCACs could play expanded role as direct home care providers

Doris Grinspun, the executive director of the Registered Nurses Association of Ontario (RNAO) has been a tireless defender of public not-for-profit health care. We’ve seen her speak truth to power at numerous conferences and public events. When she advocates on behalf of the RNAO, she speaks plainly and passionately.

Last month the RNAO released its submission to the government on Ontario’s seniors care strategy.

The document is full of good recommendations, from strong staffing standards in long-term care homes to a broadening of the policy lens to include government’s impact on the social determinants of health.

The biggest surprise, coming out during the same month as the Hudak health care platform, is the RNAO’s recommendation that the Community Care Access Centres be scrapped and the work be redistributed to the Local Health Integration Networks and to primary care providers, such as family health teams, community health centres and nurse practitioner-led clinics.

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Is competitive bidding in home care done? Let’s hope so.

September 10 Doris Grinspun, executive director of the Registered Nurses Association of Ontario, tweeted that Health Minister Deb Matthews had just announced to a nursing meeting that the moratorium on competitive bidding in home care would be made permanent. No formal confirmation of this announcement has been made by the Ministry of Health.

No services competition has successfully taken place since 2004 when then Health Minister George Smitherman announced the appointment of Elinor Caplan to conduct a review into the competitive bidding process.

The Caplan review followed months of campaigning in the Niagara region after the Victorian Order of Nurses had lost the local home care nursing contract during its centenary in the community. OPSEU-represented VON members had met with MPPs up and down the Niagara peninsula to point out problems with the competition.

The union complained that the bidding process had been tainted by the then Niagara CCAC administrator who told at least one patient in advance of the competition that VON would not be a successful bidder.

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Stories we couldn’t let pass by this week

CCACs hire 144 direct care nurses

This month the government announced 900 new nursing positions to come from their 2007 commitment to 9,000 new nurses for the health system. Among them are 144 nurses who will go into the schools to support early identification and intervention of students with potential mental health and/or addictions issues. The nurses will assess and develop plans of care, provide direct service for mild cases, and offer support and referral for more complex issues. What’s particularly interesting about this initiative is these nurses will be working directly for the Community Care Access Centres, the first new hires to provide direct care since Bob Rae was in the Premier’s seat. When Mike Harris changed the NDP’s multi-service agencies into the CCACs, he insisted that a strict purchaser-provider split exist, hoping to divest all direct care workers to private agencies. He never entirely succeeded – OPSEU still represents CCAC home care therapists that were supposed to be divested by 1998. The fact that the government has placed these nurses into the employ of the CCAC is a hopeful sign that the terrible Harris-era competitive bidding process may quietly be coming to an end. While Deb Matthews publicly said competitive bidding would return, OPSEU members are telling us the agency contracts are all being extended again.

Merging surgical departments in Windsor

A zero base budget for hospitals is forcing many administrators to look at novel ways to make ends meet. In Windsor much has been made about Finance Minister Dwight Duncan’s proposal for a very expensive mega-hospital, however, the two hospitals are looking at integration options that might save money in the meantime. Windsor Hotel Dieu is pushing for greater coordination of surgical departments with the Windsor Regional Hospital. Facing a $700,000 operating room budget deficit, Dieu is hoping costs could be saved by having the two hospitals move into even greater specialization than currently exists. Dieu presently specializes in trauma and neurosurgery while WRH does most of the pediatric surgeries. WRH CEO David Musyj told the Windsor Star he was cautious — concerned that Hotel Dieu’s financial problems could put more pressure on his 11 operating rooms.

Harper attacks Council of Canadians

Our friends at the Council of Canadians are under attack by the Harper government for encouraging Canadians to overturn elections of seven Tories elected in ridings involved in the so-called robocall scandal. According to the Ottawa Citizen, the Federal Tories hope to overturn lawsuits that seek new elections in the ridings. The Tories are basing their bid to throw out the lawsuits on an obscure and ancient legal prohibition against “champerty and maintenance,” which the Citizen describes as “meddling in another party’s lawsuit to share in the proceeds.” While the Council of Canadians would not stand to gain anything monetarily from the actions, the Tories highlight a Council fundraising campaign that notes the challenge among its work. Of course the Tories have no problems with right-wing organizations, many with American funding, helping to litigate against such left-wing institutions as Medicare. That includes the Canadian Constitution Foundation, an extreme right-wing group based in Alberta that supported Lindsay McCreith and Shona Holmes in their 2007 case intended to open up Ontario to two-tier private health insurance. While the CCF doesn’t say where their money comes from, they do specifically note on their website that they have charitable status with the U.S. Internal Revenue Service. Like the Council of Canadians, the CCF lists its McCreith/Holmes case as among the worthy activities it undertakes to solicit donations.

A tale of two physiotherapists: Why professionals oppose competitive bidding in home care

Sharon and Jackie (not their real names) are experienced physiotherapists nearing retirement. Both do exactly the same public home care work within the region covered by the Champlain CCAC.

Sharon works in the Renfrew area. Jackie works within the City of Ottawa.

The two began their community physiotherapy work as municipal employees in 1992 and 1988 respectively.

When the CCACs were formed, the service transferred from the municipalities to the provincially-run centres. While that also meant transferring from an OMERS pension plan to a HOOP plan, the physiotherapists were told they would experience no actuarial loss. This turned out not to be true, and has been the subject of a lengthy court case about to enter its second decade.

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