Presentation to the Ontario Health
Consultation on Long Term Care
February 22, 2001
Frontenac-Kingston Council on Aging
I. Frontenac and
Kingston Council on Aging: Who We Are and What We Do
II. Our Definition of Long Term Care
IV. Long Term Care Issues in Kingston and Area
V. Under Funding
VI. Waiting Lists
VII. The Human Dimension
IX. Other Issues
X. Long Term Care for Older Inmates in the Penal System
I. FRONTENAC KINGSTON COUNCIL ON AGING:
WHO WE ARE:
The Kingston Frontenac Council on Aging is a charitable organization with an annually elected Board of Directors. The Council was founded in 1991in response to the identified need by the local Social Planning Council and the Senior Citizens' Association for a planning and advocacy organization to address the local needs of seniors. membership is open to anyone who has an interest in the issue of aging.
We are a member of the provincial organization of Councils on Aging and on June 22, 2000 we became an affiliate of CARP, Canada's organization for the fifty plus.
WHAT WE DO:
As issues are identified through environmental scanning or through consultation calls by local, provincial or federal government, agency or organization, the Council on Aging strikes a committee to study the issue, and to prepare the brief which will include recommendations.
Seniors living in our community also bring issues to the attention of the Council on Aging. In some instances the issue is such that we can support the group or individual in resolving the problem. In other cases the issues has broader implications for the community and in this instance we will hold a public meting, develop a working group, and pursue the appropriate resolution.
II. OUR DEFINITION OF LONG TERM CARE:
Long term care for the purpose of this presentation will be:
Much of what we have written in our full presentation, you will have heard many times over and it is simply another snapshot of the systemic issues which are consistent across Ontario:
In addition, we briefly outlined our concern for elderly prisoners incarcerated in our local correctional institutions where there is a paucity of long term care planning or services as reflected in our 1999 study on this issue.
There is a human dimension to the issue of long term care in both the institutional setting and the home setting. The following are some of the constant threads that we heard:
- baths only once a week; diapers and liners changed, not as needed, but when staff time permits;
- personal support or help with daily living is not provided at the level needed;
- behavioral needs of residents with Alzheimer's disease and dementia are not being appropriately met;
- 60 hours a month for a long term care patient at home is inadequate for the familial care givers who often end up ill and unable to continue to provide the care at home.
- the difficulty of providing attractive and nutritional meals each day on a budget allocation of $4.68 per resident.
Need for Local In-depth Study:
As we reviewed the stories that some of our members shared with us, the committee realized that there is a need for a local in-depth study of the general issues we have raised about long term care and community care in order to bring forward meaningful recommendations to government which are specific to our area rather than just general in nature.
The Council on Aging and the members of this committee are committed to undertaking this work which we will forward to you on completion.
There is a need to develop an in-depth local study of issues identified by our cursory consultation in order to bring forward meaningful recommendations to government which are specific to our area.
IV. LONG TERM CARE ISSUES IN KINGSTON AND AREA:
TRENDS IN INSTITUTIONAL SETTINGS:
As identified in numerous provincial studies but most clearly in the October 2001 newsletter for Ontario Legislators by the Ontario Association of Non-Profit Homes and Services for Seniors which was headed "Long Term Care in Crisis": There are two conflicting trends - continued under funding, and an older and sicker resident population. These trends are causing major stresses in the system.
OLDER AND SICKER POPULATION:
Over the past two decades, the average age of long term care residents has increased from about 73 to 86 years. The typical resident today is not only older but also sicker when they enter a long term care facility. Additionally many seniors do not have immediate family in the vicinity who can provide care in either their own home or in the long term care facility. This trend will increase since Kingston is now second only to Kelowna, B.C. as retirement city of choice.
With the closing of hospital beds in our area, chronic care, formerly provided within the general hospital, setting has been transferred to the long term care facilities. OANHSS advised that this care now involves intravenous feedings, would dressings, and palliative care and special support for residents with Alzheimer's disease and other forms of dementia as well as those with psychogeriatric care, behavior intervention and special support.
V. UNDER FUNDING
The primary objective of the Canada Health Act (CHA) is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial barriers. The give principles of the CHA are:
3. Public Administration
4. Public Comprehensiveness and
Needless to say the federal government has not amended the CHA to cover long term care and home care despite the 1997 Liberal government's wide consultation and the resulting report which concluded that home care should be considered an integral part of the publicly funded health services with national standards. Not only are national standards not to be seen but they were abandoned by the Liberal government in the health care negotiations with the provinces this past summer.
Since 1986, the federal government has cut transfer payments of close to $36 billion. The Liberal government in 1995 slashed health care payments to the provinces by 33%. The increase announced prior to the last federal election is only a small percentage return of the money taken out by both the Conservation and the Liberal federal government.
Recommendation #2: The Canada Health Act must be amended to provide both national standards of home care and long term care and to ensure that both services are part of the publicly funded health care service.
Recommendation #3: If, on consultation with actuaries, the cost of long term care is prohibitive and is not supportable from the existing or projected income tax base, and insurance system similar to the Canada Pension Plan should be established to ensure adequate long term care in both home and institution for our aging baby boomers and future generations.
The provincial government used the federal cutbacks to transfer payments as their reason to chop their health care funding across the board, at the same time as the population is aging and the demand on health services will increase. Failing to plan for the aging population will ensure the system will fail.
Members of out committee raised the question: "Is this an engineered crisis in order to implement privatization of our whole health care system. Is Medicare unable to meet the needs of our sick citizens because of alleged waste, incompetence and inefficiencies and is it true that private companies will provide a better managed more efficient and less costly health care delivery system?"
The best available proof that privatization will increase spending is the American health care system. It is the most expensive in the world yet leaves millions without health care. For less per capita spending ($1,599 U.S. in the United Stages compared to $1,444 U.S. in Canada, we cover everyone for a wide range of basic services while the U.S. system covers only the poorest, the oldest, the disabled and the military.
Under funding Long Term Care Facilities:
In Ontario, long-term care facilities receive an average of about $100 a day for each resident. Of this, about $60 is paid by the province, one of the lowest rates in the country according to the Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS). The balance comes from client payment.
In our research, we learned that there is a significant problem related to the way in which long term care funding is determined. It appears to be based on the chart assessment carried out in a long term care facility once a year by Ministry of Health staff.
According to OANHSS, each registered nurse in a long term care facility now looks after an average of 60 residents during the day shift and 100 residents during the night shift. Barring any medical emergency or routine tasks such as dispensing medicine, this would leave a day shift nurse only 8 minutes to complete a patient's chart and only 4.8 minutes to complete the chart for each patient during the night shift. Yet the patients' charts on a given day provide the basis for the next year's funding since they supposedly address the issue of light care and heavy care patients.
Funding has not kept pace with the escalating needs of the residents and it is estimated by OANHSS that the shortfall is now at least $230 million a year.
Recommendation #4: The Ontario Health Coalition need to investigate the current practice of funding long term care facilities and issue a report on their findings as the first step in changing the inadequate funding process.
Under funding Home Care:
Out of hospital means out of health care! Patients are being discharged sicker and quicker from hospitals and now pay directly out of their personal pockets for drugs, some tests, and sick room equipment previously provided in the hospital. Similarly there is an extra billing for prescription drugs required by residents in a long term care facility and as regulated by the Ontario Drug Benefit Plan.
Through underfunding of hospitals, community care access centres and long term care facilities, the cost of health care has shifted to individual citizens in a variety of ways. More and more the almost full-time unpaid nursing care of the sick is being shifted to patients' relatives, friends and neighbors or it is not being provided at all.
Increasingly nursing care of sick, frail elderly people, in both their homes and in long term care facilities, is being provided by elderly frail spouses who have neither the physical resources to undertake the care nor the financial resources to purchase private nursing. In other cases, the nursing cares falls to a family member or to friends and neighbors. While "a community caring for an elderly member", sounds wonderful and loving, the reality is the opposite. It is frightening to be very ill and not have access to professional nursing and it is just as frightening to suddenly become the main care giver without training or professional support. The stress is overwhelming and does, on occasion, lead to the collapse of the primary unpaid caregiver.
Recommendation #3: Homecare and long term care must be included in a new national strategy on health care to ensure universality, accessibility, comprehensiveness and affordability.
VI. WAITING LISTS
Under the current legislation, each long term care facility must set aside 40% of the beds for subsidized patients. The balance or 60% of the beds may be held for full pay patients. This results in a longer wait for placement in a long term care facility based on ability to pay rather than on need. Lower income seniors are further penalized since they cannot afford to purchase private home care services to augment the maximum of 60 hours per month of home care provided through the local Community Care Access Centre; an option available to the higher income seniors.
Recommendation #6: There should be an amendment to the provincial legislation removing the 60/40 ratio of full pay residents to subsidized residents within long term care facilities. Placement should be based on need rather than on financial status of the patient.
VII. THE HUMAN DIMENSION:
Because long term care facilities and the Community Care Access Centre have little choice, the most common response to the under funding of long term care is to reduce the level of individual attention and care:
- baths may be given only once a week;
- diapers and bed linens are not changed as needed but when staff have time;
- personal support or help with daily living is not provided at the level needed;
- behavioral needs of residents with Alzheimer disease and dementia are not being appropriately met; and
- the list is endless
Some of our committee members suggested the under funding was resulting in "government sponsored elder abuse"
We heard more than one story of how the unmet needs of a frail elderly sick person was devastating to the health and the well-being of the familial care giver. Downloading the care giving to a family member is not "revenue neutral" when the health of the care giver is adversely affected or when a younger care giver must give up paid employment to provide the care we expected would be universally available to us as we grew older.
Nursing staff and health care aides are stretched to the limit because of inadequate funding:
- resident care staff are looking after more people with higher care needs;
- in long term care facilities, each registered nurse now looks after an average of 60 residents during the day shifts, and 100 residents during the night shifts;
- employees, including administrative personnel, are helping out with certain duties such as helping to feed the residents due to staff shortages;
- as reported by the Ontario Association of Residents Councils, families of residents and the residents themselves are commenting on the fact that the nurses and the resident care staff are now working so hard that they have less time than they used to for social contact and they really miss it.
IX. OTHER ISSUES
Recommendation #7: Additional training for care givers needs to be provided in order that they may recognize pain through observing body movements and facial expressions of patients who can not otherwise express their needs.
It was pointed out to the committee that how the familial care giver's spouse or parent is treated has a lot to do with the health of the familial care giver's own physical and mental health.
Recommendation #8: There needs to be a care giver support program developed and provided to familial care givers to provide techniques to creatively address issues which arise in long term care facilities such as over-sedation.
Recommendation #9: The issue of public financing of profitable private long term care facilities should be brought to the attention of the public so they may examine the premise on which this decision was made by the Government of Ontario.
X. LONG TERM CARE FOR OLDER INMATES IN THE PENAL SYSTEM
During the summer of 1999, the Council on Aging with the support of some of the inmates at a local penitentiary, identified the issues affecting the older inmates in our penal system. These include but are not limited to:
- the lack of training for prison guards in order to recognize hearing loss when an older inmate did not respond to an order with the result of punishment for the older inmate;
- the mobility limitations of an older inmate with osteoarthritis or rheumatoid arthritis which made it difficult to get to the dining room in the prescribed time period;
- the lack of adequate palliative care facilities within the prison system
- the need for more frequent urination by older men with prostate problems than is permitted during the working day;
- the requirement to participate in training or exercise programs which are not age appropriate.
Recommendation #10: There is a need to establish training for staff in understanding the physical realities of the older prisoner.
Recommendation #11: Guidelines must be established for the provision of the medical treatment of older prisoners as well as for the provision of long term and palliative care to older inmates in our penal system.
In addition, the Kingston Frontenac Council on Aging endorses the 32 recommendations contained in CARP's 1999 report "Putting a Face on Home Care". The recommendations were developed by the participants of CARP's National Forum on Homecare which focused on the informal caregiver and are compatible with our recommendations.