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Made in Canada solutions: answers to seniors' care challenges can start at home

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While there’s no one solution to the challenges in seniors care stemming from Atlantic Canada’s aging population, many ideas for adapting the system and improving at-home supports have been discussed and piloted. Currently, “home first” is a mantra and more programs are being rolled out to help people age at home, offering the promise of better outcomes. 


Help begins at home

There is no denying Canada’s population is aging.  

“In 2018, one out of two Canadians was at least 40.8 years (old),” Statistics Canada reported this year. “The median age has increased by 10 years since 1984, when it was 30.6 years.” 

The numbers are stark, and they tend to fuel a lot of “generational angst,” as Newfoundland and Labrador Seniors’ Advocate Suzanne Brake refers to it.

Suzanne Brake
Suzanne Brake

Brake says Canada’s demographics are not news. And it’s a disservice, she says, when the language we use to talk about the aging population in Atlantic Canada makes it all sound like an impossible challenge. Phrases like “grey tsunami” or “silver tsunami” unfairly suggest devastation, an inability to function, as opposed to something to adapt to, she told SaltWire Network. 

Seniors’ advocates say people need to remember that most older people are not in a care home or a long-term care facility. When we need some help with day-to-day living as we get older, that help actually comes first from friends and family. 

“Where we think about caregivers, we often first think about paid caregiving,” said Laura Tamblyn Watts, chief public policy officer with the Canadian Association of Retired Persons (CARP), who said unpaid caregivers are starting to receive more recognition.

This year, it’s estimated 5.9 million Canadians will provide care for nearly 1.7 million people aged 65 years or older. 

Laura Tamblyn Watts
Laura Tamblyn Watts

And there is a lot of thought being given to ways to support caregivers. 

CARP says there’s room for the federal government to offer more financial help. They’ve put a specific request on the table to make the Canada Caregiver Tax Credit a refundable tax credit, as opposed to non-refundable. 

“Right now, you have to earn external money to be able to claim the caregiver tax credit,” Tamblyn Watts said, noting people with low income or who are out of the workforce don’t benefit. 

“All we want to do is to have them make it a refundable tax credit; so, it comes off general taxes, it doesn’t come off the income.”

Credits not being used

In February, the Conference Board of Canada reported existing federal programs meant to help caregivers are underutilized, and only 4.6 per cent of all caregivers receive money through relevant federal tax credits: the disability tax credit, medical expense tax credit and caregiver tax credit. But even if you made these tax credits refundable, it stated, they’d still be underutilized — unless they are also better advertised and made easier to claim. 

Apart from tax credits, another option for financial help for families is a new seniors’ care benefit. 

“If the federal government covered 50 per cent of all out-of-pocket seniors’ care expenditures, it would increase total federal reimbursement of private-care expenditures to $11.8 billion by 2035 — a net increase of $6.9 billion over the status quo,” the Conference Board reports, warning that for now, income growth is being outpaced by the growth in expenses for aging at home.

More broadly, CARP and others, including the Canadian Medical Association, are promoting the idea of a national seniors’ strategy. 

PUBLIC DECISIONS

“Canada’s medicare system is not threatened by a silver tsunami of aging baby boomers. It is threatened by a tsunami of ‘more, more, more.’ It is threatened by an unwillingness to ask if more intense, more expensive care is appropriate or necessary, and a reluctance to reallocate dollars to strategies that work and to cut (or off-load) those that do not.”
— André Picard, Globe and Mail Health columnist, “Matters of Life and Death” (2013)

No place like home

Provincially, a variety of “home first” programs have been tested in recent years, offering new direct supports so that more Atlantic Canadians can stay in their homes as they age.

On Prince Edward Island, the Caring for Older Adults in the Community and at Home (COACH) program has received national recognition. 

It involves a home assessment by a geriatric nurse practitioner. They will identify things that can be done to help seniors in their home, making decisions in co-ordination with the person’s primary care provider (doctor or nurse) and a home care co-ordinator. The program is aimed at seniors with complex physical and psychosocial needs.

Prince Edward Island also found early success with a Paramedics Providing Palliative Care at Home program, established in 2015. 

Through that program, when home care is not available (for example, after hours), residents can call 911 for palliative paramedic services. Paramedics trained in palliative care then provide additional pain medication or therapy, based on a pre-approved care plan, and consult with a doctor by phone as needed. 

When seniors move out of their own homes, care options differ by name throughout Atlantic Canada. 

“When caregivers need help, they turn to the internet and their friends and family long before looking to the health care system for help.”
— The Change Foundation, “Spotlight on Ontario’s Caregivers” (November 2018)

“Continuing care services do not fall within the Canada Health Act, and therefore have developed in the 13 jurisdictions in a piecemeal way creating what is often referred to as a patchwork quilt of services,” the Health Association of Nova Scotia noted in a 2012 jurisdictional comparison. 

That makes it harder to talk about, compare and evaluate improvements in a universal way. 

But across the board, the need for more space at nursing homes facilities is recognized, with requisite staffing.

In Nova Scotia, a commitment was made earlier this year to act on all the recommendations from an expert panel review of long-term care. Among other things, the panel was critical of staff-to-patient ratios in long-term care facilities.

“We heard over and over from residents and their families that staff do not have time to provide appropriate care because they are ‘working short,’” the panel said, as the Canadian Press reported in January.

While home first programs reduce institutional demand, there is still demand, and improving the advanced care system for seniors — whether adding long-term care spaces through new construction, or by improving staffing ratios — will require new injections of funding into the care system. 


CHANGING APPROACH

“Since 2003, home care programs have focused on increasing access to care, expanding the range of services offered, facilitating coordination and integration, and recognizing the vital role of the family caregiver.”
Accreditation Canada and the Canadian Home Care Association, “Home Care in Canada: Advancing Quality Improvement and Integrated Care” (2015)


Challenges and responses —
Success stories

Challenge: Senior friendly housing

It’s difficult to age at home in a house that was not designed for people with limited mobility and agility.

Response:

The municipality of Caledon, Ont., was aware that its population was aging and it was hearing an increasing demand for appropriate housing for seniors.

In 2009, according to a report from the Canada Mortgage and Housing Corporation (CMHC), the town decided to do something about it.

It created a policy that would see any new housing development have to offer at least one floor plan with universal design features, such as wider hallways and doors, kitchen counters of varying heights and plug outlets installed higher up on walls so they can be reached more easily.

“Many of our seniors want to stay in Caledon as they downsize,” Marisa Williams, a senior policy planner with the town, told CMHC.. 

“But with the high land values in Caledon, developers weren’t building the kinds of homes that seniors want to live in, like bungalows and senior continuum communities. Our Official Plan, at that time, didn’t have a clear policy to address issues like accessibility or aging in place, so council decided to make universal design part of our core housing policy.”

The town worked with developers and builders to explain the benefits of the plan, which does not only accommodate seniors, but people with a range of disabilities.

The universal design policy is now part of Caledon’s Adult 55+ Strategic Plan.

Challenge: Social isolation

For seniors who live alone, the lack of social connection can have adverse health effects.

Response:

In the Peel Region of Ontario — and in other Ontario jurisdictions, the Telecheck Seniors Program for people 55 and older has trained volunteers who call clients of the service for regular check-ins.

It’s well recognized that loneliness and isolation can harm a person’s health.

A column titled “Secrets to Successfully Aging in Place,” by Bob Carlson in Forbes magazine (July 2018), notes, “Perhaps the most important factor in aging well is having social interaction and connections. … Lack of personal contact and connections leads to depression and loneliness. People deteriorate faster both mentally and physically when their social connections are reduced. Older people who are active socially tend to be happier and healthier.”

In the Peel Region, Telecheck is offered for free in English, Cantonese, Mandarin, Portuguese, Spanish, Hindi, Punjabi and Urdu. Callers can remind clients to take their medication, check to ensure they’re safe, offer emotional support or just have a chat.

Challenge: Improving dementia care

Antipsychotic medications are sometimes used inappropriately in long-term care and can actually cause a decline in cognitive function among seniors with dementia.

Response:

In 2018, the Canadian Foundation for Healthcare Improvement (CFHI) and the government of Newfoundland and Labrador embarked on an 18-month pilot project to more closely regulate the use of antipsychotic drugs in long-term care.

“In 2016-17, about 22 per cent of residents of Canadian long-term care homes were on an antipsychotic without a diagnosis of psychosis, but just five years ago that rate was 32 per cent,” said CFHI president Maureen O’Neil. “Our experience supporting the appropriate use of antipsychotics across Canada demonstrates that it is possible to improve dementia care and reduce the inappropriate use of these medications through person-centred approaches.” 

Health-care teams identify patients who might benefit from non-drug interventions to treat behaviours associated with dementia and work with their families to devise personal care plans.

The Newfoundland and Labrador project is part of a pan-Canadian effort by the CFHI which has already demonstrated success. 

According to CFHI:

• There has been a 54 per cent reduction in the inappropriate use of antipsychotics, with significantly less socially inappropriate behaviour, resistance to care and a 20 per cent decrease in falls. 

• Phase 1 of an initiative in New Brunswick saw a 43 per cent reduction in the inappropriate use of antipsychotics and the number of falls decreased by one-third. 

• Residents who had their antipsychotics reduced or eliminated became more socially engaged, were better able to eat independently, and became more wakeful, improving the experience of care for families and staff. 

RIGHT PLACE AT THE RIGHT TIME

“Measures to reduce the number of alternate level of care patients in acute-care hospital beds … could contribute substantially to improved value for money in long-term care.”
C.D. Howe Institute, “Long-term care for the elderly: Challenges and policy options” (2012)

Challenge: LGBTQ+ friendly long-term care

Some gay seniors worry they will be essentially forced back into the closet if they move into a care facility.

Response:

More long-term care facilities are letting their colours fly, raising Pride flags and signalling their welcoming attitude to all seniors needing care.

True Davidson Acres in Toronto is one such place. It touts itself as being LGBTQ+ friendly and Pride celebrations are held annually.

In an article in Toronto’s Xtra in 2012, Camille Orridge, CEO of the Toronto Central Local Health Integration Network, acknowledged it may not be as easy for gay seniors to find appropriate long-term care outside Canada’s largest cities.

“There absolutely is homophobia and transphobia,” she said.

But change is coming. 

In a piece for the Ottawa Citizen in April 2018, Paul Leroux wrote about his experience living at Extendicare Medex in Ottawa with his husband, Alex Wisniowski, where Leroux helped staff organize the facility’s the first Pride Week celebration last year.

“As a gay couple, we have been not merely accepted but embraced. We have been able to show our love quietly but openly…,” he wrote. “I have found a new home and a new family. This is what a long-term care facility, at its best, can be: a home in the truest and noblest sense of the word.”


WAY OF DOING BUSINESS

“Employers perceived that the most effective benefit when it comes to retaining talent are subsidies for eldercare services, with 92 per cent of employers (U.S.) describing the benefit as either very effective or somewhat effective. Yet, fewer than 10 per cent of employers offer the benefit, despite the fact that 32 per cent of workers who left a position over care concerns did so because they had to care for a senior with daily needs.”
Harvard Business School (2019), “The Caring Company: How employers can help employees manage their caregiving responsibilities”


Geriatric nurse practitioner Kristen Mallard visits with John Nolan in this screenshot from the COACH Program video.
Geriatric nurse practitioner Kristen Mallard visits with John Nolan in this screenshot from the COACH Program video.

The COACH Program — how it works

Like most programs with a COACH involved, the aim with this one is to win.

But the Caring for Older Adults in Community or at Home (COACH) Program in Prince Edward Island tries to ensure everyone’s a winner — frail adults, their families and the health-care system generally.

Through COACH, a geriatric nurse practitioner visits elderly Islanders in their homes to help determine the medical and psychosocial supports they need to help them stay there as long as possible. Then, working with a health-care team, the supports are identified and provided.

COACH started as a pilot project in Montague, P.E.I. in 2015 and has since expanded into Souris, Summerside, O’Leary and Queens County.

Geriatric nurse practitioner Kristen Mallard is featured in the video explaining the program.

“My job is to support older adults living at home,” Mallard has said. “We’re empowering people to be in control of their own lives with the ability to make decisions. It matters because they’re in their own home … they’re sleeping in their own beds, and they’re surrounded by the people that they love.” 

COACH helps keep people at home and out of emergency rooms and hospital beds if more appropriate and timely care can be provided at home with some help.

In September 2018, COACH won the Canadian Frailty Network’s Conference Choice Frailty Innovation Award at a national conference in Toronto.

The Canadian Frailty Network praised the program’s benefits and measurable results: “The COACH team provides direct client care at home, on a timely basis, in an effort to predict and prevent (or proactively manage), health crises when they occur and ideally decrease the need for emergency services or admission to hospital. … 

“System utilization data from the COACH pilot (program) demonstrated decreases in hospital inpatient stays by two thirds, emergency visits by one third and primary care visits by one half. 

“COACH clients are better able to self-manage and make informed decisions that positively impact their quality of life at home and, when necessary, support smoother transitions to and from acute care or long-term care.”

COACH may not be adaptable in larger provinces where communities and health-care supports may be more far flung, but in more compact P.E.I., it is making a difference.

“What we know is loneliness contributes to depression, loneliness contributes to anxiety.”
— Susan Sullivan, the Quality Living Alliance for Seniors, interview with The Telegram (2019)

On the P.E.I. government website, Murray MacPherson describes how COACH was able to help get his 82-year-old father, Scott MacPherson, home from the hospital where he was being treated for a bladder infection and provide “five-day-a-week care and assistance that the family could not.” 

The senior MacPherson was able to spend another year at home before transitioning to a long-term care facility in Montague.

“My family would not have gotten the time it did with my father at home if not for these programs and their caring and supportive staff,” Murray MacPherson said.


PERSONAL DECISIONS

“Understand that the care receiver is responsible for decisions about his/her own care. The care receiver should be present as often as possible for all discussions about him/her, and supported decision-making should be available if needed.”
— SeniorsNL, “Guide for Family and Friend Caregivers” adverse


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