That was the headline of a CBC story carried on the news on June 5, 2020; the story went on to discuss the issue of inadequate home care in New Brunswick as illustrated by the case of Paul Ouellet’s sister, Lorette. And the issues of inadequate funding of home care in New Brunswick were well documented in the Council on Aging Report.
In the story, the health authorities’ position of “move long term care to health” was recited again by Karen McGrath, CEO of Horizon, in which it was noted that she has been asking for structural change for two years. The structural change referred to is to move long term care to the Department of Health or to the health authorities, the theory being that somehow that would improve the flow of persons requiring long term care more smoothly and expeditiously. This is also a position taken strongly by unions.
Oh, that it was all that simple. However, achieving reform of long-term care in New Brunswick requires significant change at deeper levels; otherwise, we are just “moving the chairs on the deck of the Titanic”. New Brunswick has wasted countless tens of millions of dollars in executing “restructurings” that were not well thought out. Ask any veteran of NP Power for a few illustrations!
In the decade invested in my initial education and training the first thing that was drilled into us as “budding executives” was to make sure we have a grip on facts before making an executive decision. Decisions made without evidence and factual base usually rebound and fall flat later on and cost huge sums of money! In continuing education experiences, we were trained to “ask why 15 times” in trying to get to the root of issues. That was the mantra of Lean Six Sigma, a powerful process used to re-engineer many systems for Toyota, Canada Post, and countless other Fortune 500 companies.
In the pandemic, the province that has had the best record in terms of fatalities thus far has been the province that has health and long-term care in separate departments! How ironic is that? And in this province, we enjoy a mix of private sector and public sector systems. Almost all of special care, or Level 2 care as is Level 3B and 3G care is private sector and works pretty well despite the inadequate compensation levels reimbursed by government for incredible staff. Owners and operators are vested in the success of their businesses, whether 6 beds or 100 beds, and the ones I know live with their businesses, taking the pressures home with them at the end of the day, 24/7.
Home care is much the same, all run by struggling private sector organizations that provide basic service limited by a scanty reimbursement provided through the government system.
Learning from the pandemic, there appears to be no correlation between which department houses the direction for long term care and incidence of infection or death. We will not have full factual evidence for some time, but based on experience thus far, Covid-19 has claimed lives of the frail elders who tend to be, due to their health status, housed in long term care. And there have been fewer deaths from Covid-19 than experienced in the same time period as a result of the seasonal flu. So, neither ownership nor department of oversight and direction seem be factors based on evidence available at this time. What does seem to be a factor is the style and character of the facilities in which frail elders share rooms such as the old style 4-bed wards, a design feature based on old hospital design thinking.
The health authorities have had years to build bridges to long term care in New Brunswick and thus far have failed to do that in a meaningful way. Building bridges and working together requires no structural or legislative change. Indeed, a long-standing partnership relationship between Horizon and 5 nursing homes has been fraught with huge communication problems and issues of trust to the extent that the arrangement has fallen apart.
Some 45 years ago, Ron Crawford, who later became Director of the Nursing Home Services Branch at the Department of Health and Community Services, created a small organization (Health Services Management Inc.) that provided shared services to 5 small nursing homes in Region 2 and 3. Through this simple structure, they shared CEOs, Directors of Care, Accounting and purchasing and served their communities very well while not duplicating overhead. Each of these sites had, as well, an adjoining health centre managed by Health Services Management that provided primary care services and baseline urgent care to the community along with lab specimen collection. In the early days of Hospital System Regionalization in the 1990’s we maintained that relationship working through the challenge of operating rural health centres and providing support to the nursing homes. To be successful, it required a tolerance for some ambiguity with different branches of the Department of Health and community Services involved at regulatory level.
The important thing was that the local service was quite good with ambulance, health centre, and nursing home basically on the same site in the same small communities. Staff knew each other and supported each other in the various services. It was integrated service at local level long before discussion of integration became fashionable! It just happened with the good will of collaborative people.
With the clinics, nursing homes and ambulance services there were integrated joint health and safety programs, continuing education, and a good deal of collegiality. That has not existed now for a few years.
As time has elapsed and Horizon replaced the simpler regional hospital corporation, the entire set of relationships began to change. Now ambulances were quite separate, the communication barriers became a challenge, and the homes were treated as second class facilities. One home described the relationships as they have developed in recent years as “an iron wall between the nursing home and the clinic”. I am reminded of the old phrase: “they may forget what you say but they will never forget how you made them feel.”
The emerging relationships demonstrated just how different long-term care and acute care are in philosophy, orientation, mandate, structure. The relationships between Horizon and these 5 homes deteriorated to the point that they sought legal counsel and took steps to extricate from this long-standing relationship. These homes now are doing some leading-edge things in the care of frail elders with a sense of pride that was, in their words, compromised by the complex set of relationships that prevailed for years. Other major areas of deterioration in the relationship relates to the Human Resources management function. It has often been said that it takes a special type of person to work in a nursing home and that must be considered when making human resources decisions. One misplaced person can create mayhem in the tight atmosphere of a nursing home.
A major lesson confirmed with the pandemic is the huge gulf of understanding between acute and long-term care. Acute care is all about rapid turnover, diagnosis, treatment, release. Long Term Care, on the other hand, is all about keeping the resident safe, well nourished, as active as possible, enjoying life to the maximum of their capability.
Ken McGeorge,BS,DHA,CHE is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News. His email address is firstname.lastname@example.org.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.