A Continuing Care System that Works for Seniors

Marcy Cohen, Canadian Centre for Policy Alternatives - BC

The home, the people that run it and work in it are good people. They make you feel like they care and they do…I would say the effect of this community has a great deal to do with my health. As long as there is a community that cares and that I care about, I’ve got a reason to keep on living. If I don’t have any of that, I might as well die.

Frank

I just heard that these little luncheons will no longer take place. I don’t know what to do to fill the gap. I can’t very well just go to White Spot and sit down at a table and hope somebody will talk to me. So I’m going to miss a great deal when they take away these outings. And who knows I might become very sick, I might become very blue. I don’t know what’s going to happen to me. I don’t even like to think about it, really.

Bess

Even if I don’t hear by email from any of the kids or the grandkids or…the son in Delta is too busy to get in touch with me. It is very easy to feel deserted and alone. And it’s going to be one of the worst things to swallow if this program does totally go down.

Some days when I’m sitting here feeling blue, and the phone will ring and it will be them. All of a sudden, even it it’s grey outside, the sky goes blue again. …just those little things make all the difference.

Heather

Despite all the wonders of modern medical technology, seniors share with all of us the raw and basic need for dignity and human connection. What I now understand is that this has to be the primary focus of how society looks after our elders and how we think about health care for seniors

Linking Social Support to Better Health

Canadian Public Health Agency recognizes social support is a determinant of health:

Social engagement and the frequency of social contacts reduces the risk of dementia, slows the progression of disability and positively impacts longevity

Recent Meta-analysis on the impact of social relationships on mortality – comparable to smoking and greater than high blood pressure, obesity and physical in-activity

Stats. Canada study in RC, participation in social activity and feeling close to at least one staff member positively associated with self-rated health

Sweden and Denmark

Considered the best places in the world to grow old. As societies, they have decided to support public provision for both the elderly and young collectively. The goal for the elderly is support them to remain social engaged and empowered:

No matter how frail you have right to control your own life

Dependence is the slippery slop that hastens your demise

Seniors – regardless of age, income and the potential for informal care givers – are entitled to same consistent care and supports. And at the same time health care providers are guaranteed equal employment conditions.

Differences between Demark and Sweden

Sweden cut their lower levels of support and Denmark didn’t

In Denmark there is a law that everyone over 75 is offered services once a year

Overall spending on seniors community services in Denmark is 1.7% of GDP and in Sweden it is 2.4%

Canada’s “System” of Continuing Care

The 2002 Romanow report talks the fact that status quo is not an option – that health care in the 21st century is about more than hospitals and doctors.

Non-physician home and residential care is an invisible and yet increasingly essential foundation of our health system

Because they are not part of the Medicare umbrella, it is much easier to change eligibility criteria/cut services. Also because the clients, residents and workers have less status and clout their concerns are often ignored.

As a result services often very fragmented, eligibility to services is quite restrictive, many of the providers are for-profit…. Hardly the continuum of care our gov’ts claim to support.

Challenges in Continuing Care

Half the variation in risk of chronic conditions can be explained by economic factors like education and income

As we age health inequality accumulates so that people with low levels of education/income are more likely to have extended period of ill health and disability in their seniors years as compared to people from more privileged backgrounds.

More on the Challenges of Continuing Care

A small group of patients with multiple chronic conditions use a disproportionate share of health services – many of them are seniors from low income backgrounds. e.g. in Ontario recent study showed that 1% of population used 50% of hospital and home based services, 5% uses 85% of these services.

Regardless of age, we spend a 1/3 to a 1/2 of a typical person’s health expenditures is in the last year of life – and yet access to palliative care services is very limited

What Does Grab Media Attention

Overcrowding in hospitals and waitlist in emergency and for surgical procedures

These problems can not be solved within the four walls of the hospital….reflect broader system issues and in particular --

Inadequate levels of funding and poor co-ordination in continuing care and between continuing care and primary and acute care

Failure to recognize the importance of the determinants of health

Overcrowding/wait times linked to deficits continuing care

The 2004 Accord provided new $$ for additional surgeries in five areas to reduce waitlists, and national process for monitoring wait time reductions

Seven years later in the Wait Time Alliance of Canada reported on the progress made in reducing wait times stating that:

“the most important action that could be taken to improve timely access” in both emergency and elective surgical services would be to reduce the number of people, most of whom are elderly, who remain in hospital because they are unable to access long term or community care services, (Wait Time Alliance of Canada, June 2011)

Overcrowding/wait times linked to deficits continuing care

People with low socioeconomic status were more than twice as likely as people of high or average socioeconomic status to be hospitalized for chronic conditions (e.g. diabetes and mental illness) that could be treated in the community (CIHI 2008)

Rebuilding the Foundation -- a integrated system of continuing care and support for

seniors

An alternative to the current strategies of cutting hospital or community services, off loading costs to patients and privatization

Based on a growing number of examples internationally of not-for-profit regional health systems that have succeeded in simultaneously improving health outcomes and access and at the same time controlling cost increases.

They have succeeded because they operate more like a system -- working across services and provider groups and involving patients and front line staff in their improvement strategies.

The focus on improving quality, providing more integrated and appropriate care to seniors and others with complex needs and NOT COST REDUCTION

Contrasting two Swedish Counties

Stockholm, where in response to fiscal pressures in 1992, introduced Activity Based Funding and internal competitive market for hospital services

At first Stockholm was quite successful with 20% savings in 2 years but by 1997, they disappeared and productivity levels were back to where they were in 1991

On the other hand by 2005 Jonkoping had the best performance in all of Sweden in terms of efficiency, timeliness, safety, patient centredness, equity, and effectiveness.

Jonkoping took a system approach and focused on improving care for older people with complex chronic conditions and learning how to deliver more co-ordinated, evidence based quality care

End of Life Care – Gunderson/Lutheran HMO

Goal was to improve end of life care and options for patients

Introduced 3 strategies – 1)Advanced Directives (educational program as schools/churches/requirement in care) – 92% compliance2)Palliative Care teams not just for cancer3)Care co-ordination for the sickest 1% -- mostly through great use of RNs

Results cost savings and greater patient satisfaction

Examples Closer to Home – integrating Continuing and Primary Care

CHOICES day program in Edmonton – combines medical and social support from people with high needs but still living at home

HOME VIVE in Vancouver – physicians provide care at patient’s home with the support of nurse case managers who provide access 24/7

RC in Prince George/Vancouver – physicians/nurse practitioners working with a patient population in RC to establish a relationships with residents and provide a broader range of services in RC

Rebuilding the Foundation for the Seniors Population

Services designed around patient needs – i.e. role of patients and front line staff in decision making about care

Social care key component of care both within and beyond the health system

Focus on those with complex needs and on the integration of primary and continuing care services

Build alliances with the many other providers and consumer groups who support better funding for and integration of continuing care services under the Medicare Umbrella