​Long Term Care: the forgotten element of Health and Social Services

That our health services are in crisis is the understatement of the decade!  Much has been written and debated on the topic and some will suggest that “it is the same in all provinces!”  True only to a degree and a very lame excuse, at that.

Acute Care facilities in New Brunswick are under duress for many reasons.  One of the large ones is the pressure on emergency departments and on acute care beds in which elders “waiting for a nursing home bed” are said to be a huge problem.

Indeed, New Brunswick is one of the leaders in Canada for having the highest proportion of acute care beds occupied by such frail elders, according to the Canadian Institute for Health Information.  Ask a social worker, a discharge planner, a physician, and the family of the patient….” we could free up those beds for occupancy by really sick people if we could get the ALC patients to a nursing home.  But the nursing home wait list is huge and wait time for admission is months and months!”

If you believe that and take it at face value, you would believe a myth.  Just because a frail elder is not safe to live at home alone does not, in itself, mean waiting for a nursing home admission is the only option.  Some suggest that between 40 and 60% if those waiting in hospital beds “waiting for nursing home” (Alternate Level of Care) could and should be cared for in other levels of care that are appropriate for the need and which, by the way, are remarkably less expensive than nursing home.  We love our nursing homes, and I am proud of the one that I administered a few years ago, but as an option of long-term care, they are the costliest to the public purse.

Maintaining the person in their home is the first option and our systems of care do not allow Aging in Place to happen easily.  To remain at home, whether a family home or an apartment building or senior’s residence, is not easy to organize and maintain if the person requires some nursing oversight, homemaker support, foot care and other services to ensure quality of living.  It often is a nightmare for families or friends to organize and coordinate the things that could enable a frail elder with one or more chronic illnesses to reside safely at home.  Aging in Place is a wonderful concept and to make it work, there needs to be serious regulatory alignment in fields of health, social service, home care, extramural services.  Otherwise, we continue to fall victim to the silo-effect, for which New Brunswick Health and Long-Term care is famous.

Home Care services are a bit of a patchwork quilt with some superb providers of service in the province but, again, regulated in the absence of any apparent plan or strategy for long-term care.  The legislation that provides regulatory direction is the Family Services Act, not exactly designed for frail elders living at home.
Once the person cannot manage at home, even when services have been organized, the transition to a long-term care facility needs to be dealt with.  In New Brunswick we have what is loosely defined as Level 2 care which refers to facilities “regulated” under the Family Services Act referred to as Special Care homes.  There are well over 400 such homes in the province ranging in size from 5 beds to 100 beds. Some are small and managed as an extension of a large family home while others are located in a complex of long-term care facilities that include apartments and care facilities.  These represent a large unknown asset and are not managed, historically, as part of the long-term care system. 

This large sector provides services to some 7000 persons of which 1700 are in homes that tend to specialize in providing care and services to persons with intellectual and/or other mental challenges and there are some truly exceptional models in this group.  Other homes provide superb service to persons with frailty and dementia.

This sector is regulated under a financial framework that has not been modified in 20 years and has none of the features of the system in place with nursing homes.  The standards under which the sector is regulated are old and rather dated, although there is promise of updated standards “soon”.

Then there is the nursing home sector which is defined as Level 3 which implies access to professional nursing 24/7, although the majority of care is given by LPNs and persons with Personal Support Worker training alongside Activity personnel.  This sector cares for some 4900 residents and is regulated under the Nursing Home Services Act that is remarkably different from the Family Services Act. 

Within these three service sectors, there has existed vacant capacity for years due to many factors.  One of the factors is that the only waiting list for long term care that is managed is the nursing home list with no such structure governing or enabling access to care in the home care or special care sectors.

All of this results, of course, in service inefficiency and serious issues of access for residents.  The crime of it all is that hundreds of acute care beds in hospitals are unavailable for persons who need acute care.  That is a lot of beds and represents 19% of the patient days in hospitals.

The current state is a fact of history and no one can be personally accused of being negligent.  But here is the rub:  the health and social services required by humans follows a spectrum from primary to acute to post-acute to long-term.  An informed society, caring about the well-being of its taxpayers, needs to have public policy in health and social services that provides for recognition of the spectrum and eliminating barriers to the orderly flow of service based on care and service requirements.  For public policy students that is Public Policy 101!

This speaks, then, to legislative and regulatory structures that facilitate service in articulated ways.  If that were the case, the awful stories one hears regularly from patients and their families would be moderated for most of the obstacles in care and service stem from the lack of articulation between regulatory structures.  In frustration or jest, we commonly refer to that as “silos” of regulation and service.

Health and Long-Term Care need to be driven by one plan for long-term care, one set of laws, one set of regulations, one regulatory structure.  As I age and more of my friends are at the age of accessing service at some level, I confess to often feeling emotions ranging from acute frustration to acute anger.  The anger comes when I hear heart-wrenching stories of years of delay in getting pain-relieving interventions or legitimately ill patients lying in emergency for days while 40-60 beds “upstairs” are occupied by patients who should not be in hospital.

No one said reform is easy; it is tough, and it takes a special breed to direct it.  But the younger generations with thank us for bearing down and fixing this before they become service seekers.
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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