Horizon’s Critical State: again!

Minister Cindy Miles approved the implementation of the priority for admission to long-term care for hospitalized patients as recommended by a desperate CEO, Margaret Melanson, last week.   In her approval, she mentioned that government would like to ensure that level of crisis does not recur.

Newsflash!  It will and it has!  This is the second time in two years that this measure has been invoked.  As Andrew Waugh reported, in late 2023 it was invoked by the Tory government and now, less than two years later, by the Liberal government.  I was consulting with the long-term care sector at that time in 2023.

As the Premier has correctly referenced, the Alternate Level of Care (ALC) issue is not new.  Its origins extend back half a century!  In 1959 the seeds were originally planted as the Hospital Services and Diagnostic Services Act provisions were rolled out across the country.  That was the beginning of Canada’s “free hospital care system”, as it has been known on the street.

In some quarters, people seem to think this crisis “just happened”!  It has been growing under the noses of policy-makers and regulators.  It all started innocently and I recall, in the 1990’s, the debates in the DECRH about the need to levy a charge for hospital days involved when ALC patients occupied acute care beds.  The actual policy and governmental regulation were that admission to an acute care bed was restricted to those patients in which it was “medically necessary” for them to be there.  Actually, all acute care hospital services were subject to that specification:  medically necessary.  More precisely, everything done by way of admission, diagnostic tests and therapies, special nutrition, special medications, surgical procedures were governed by that those two words:  medical necessity.  The onus was on the physician, since they have been and still are, the guardians of the admission/discharge decision, to be able to justify everything based on their professional judgement of “medical necessity”.

When the patient’s acute care is dealt with it has been expected that they are discharged and the patient (or family, guardian, or caregiver) have always been responsible for arranging any living arrangements they may need after the acute phase of illness.  It has never been the responsibility of the hospital or its physicians to make those arrangements.

In the 1960’s we saw serious development of nursing homes to respond to that need for care of frail elders.  Those who could afford to hire visiting nurses often made their own arrangement for nursing and home care.  For the average citizen, that has always been way beyond reach in terms of cost.  Service clubs, church groups and other non-governmental agencies stepped up and created a number of nursing homes.  In the population, the seniors living at risk constituted a small fraction of what is now the case.
The NB Health Council has produced good information on the percentage of seniors who live with various medical conditions and who, in many cases, live at some risk.  In looking at those numbers, as frequently presented publicly by Stephane Robichaud, the CEO, the fact that there is now a crisis should come as no surprise!

For many years, if not a decade or two, attempts have been made to improve the engagement of the public sector in NB in getting a truly factual assessment of the current state and future directions.  The culture of the public service in NB has not appeared to be open to serious dialogue on these matters.  That is a culture that seems unique; some of us who have worked in other provinces have had other experiences with dialogue and collaboration.  Governments in NB seem to have been content to create a process of creating “a plan” which would then be printed in beautiful glossy format and tabled in the legislature.  There have been many serious people who have devoted months to participating in those reports only to find them not taken dreadfully seriously.

If government truly wants to “get to a steady state” with this aging care issue, it will take much more than simply a temporary change in the policy governing priority admission to long term care.  Here are the issues that have been in front of the public service for a decade or more:

1. Home Care and Home Support:  a certain proportion of persons with chronic or developing physical challenges can be managed at home if they have the proper supports:  care, nutrition, housework and more.  The percentage may not be as large as some think but it needs careful analysis.  Staff training, regulation, and compensation has been the issue that has never really gotten out of the gate.  Nova Scotia seems to have bitten that bullet but not NB.  But we have been studying it for well over a decade!  Like watching paint dry.
   
   
2. Assessment System:  this process is so central to getting and maintaining quality long term care.  The right resident with the right care requirements in the right facility that has the skill and ability to safely care for the person.  Why does something that sounds so easy get so complicated?  There have been debates on the effectiveness of the system for 20 years yet there has been little if any collegial assessment of the mechanics of the system.
   
   
3. Primary Care Reform:  The Premier states it well and the priority for Primary Care Reform was seen by many nearly two decades ago.  A succession of governments has not been too committed to making it happen.  So, NB is catching up with Dr. Dornan’s persistence.  The Tories, with a push by Minister Shepherd, had commenced this process.  But it will be years before this essential change will result in measurable changes in ALC numbers.  That is just being realistic.
   
   
4. Long-term care system:  home care, special care, nursing home care.  All three elements must be developed fully.  In terms of volume, nursing homes account for much less than half of all of long-term care.  The entire sector needs to be developed with intentionality, not in the typical crisis response, pre-election styles of response.  Governance, funding models, staffing standards, training standards, regulation.  Those are gritty issues that must get more than a nod.
   
   
5. Legislation:  two thirds of the long-term care system is “regulated” under the Family Services Act while nursing homes, 1/3 of the system, are “regulated” under the Nursing Homes Act as amended in 2015.  That would have been the time to create one Long Term Care Act but it now needs priority.  The split accountability creates far too much ambiguity and inefficiency.
   
   

As has been described in Lamrock’s What We All Want, and in many articles and commentaries, there are many more issues that need focus if the goal is to create a modern, sustainable long-term care system.  Issues of standards of service, accreditation, governance, workplace culture, labor and professional relations, standardization of practices, financing.  The sector has been raising these issues in various ways for many years.  Getting and keeping the attention of the regulators and elected officials over time has always been a challenge, to be honest.

Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at [email protected] or www.kenmcgeorge.com