Monday, February 2, 2009

LTC situation in Ontario

I was asked by a journalist about the state of LTC in Ontario. We are expecting a report in March on this issue (see references below).

What is appalling is that hospital and LTC spend $18 billion of our tax dollars in the MUSH sector: municipalities, universities, schools, hospitals which includes: LHINs, LTC, Health Care & Children's Aid TPAs*, police, EMS.

In the case in most of the institutions that care for the young (Children's Aid Societies) and related organizations: non-profit Day Care, and other sectors run by municipalities, they have requisite knowledge, skills and expertise embedded in their workforce.

In the case of the old and the frail (Retirement Homes, LTC, private TPAs), many are staffed by those without necessary qualifications. For example, to work in a Day Care I need to have my ECE degree. A degree that involves training in pedagogy, sociology, psychology at the college or university level. If I work in schools with special needs students, I must have my Special Education Specialist Certificate, which I do posses!

Those who work in Retirement Homes & LTC do not require the same expertise. Day programs and activity directors may or may not have such training and may not understand their residents. Don't get me wrong, many do, but judging by, for example, resident newsletters some do not hold basic reading and writing skills. Many excellent agencies, which provide personal home care to seniors ,only hire PSWs who have a certificate. These workers often work alone, in the residents room, or in private homes - unsupervised. Nurses, and we are desperately short of this category, do not necessarily have the added geriatric certification. Physicians definitely do not have such training. The Geriatric Assessment Program of Ottawa demands that geriatric assessment by given by a qualified team to determine needs of resident, and prevent or ameliorate comorbidities and chronic health issues.

I have written previously about the need for such assessments, and the early discharge of seniors from hospital, including depression tests in both seniors and their caregivers. With early identification of these biopsychosocial health risks we can prevent seniors from landing in emergency rooms, or LTC.

Dr. Frederick Sherman (www.geri.com), of the Mnt. Sinai School of Medicine, says:
  • Family Not Aware: 21% of family members fail to recognize a problem with memory in demented seniors. (JAMA, 277, 1997)
  • Physicians Fail to Evaluate: 53% of seniors whose family DID recognize memory problem did NOT receive an evaluation
  • Physicians Fail to Chart: 76% who screened positive for Mod/Sev D were not noted to be demented on chart review. (Ann Int Med, 109, 1995)
Dr. Michael Rachlis’s work in the area of health care calls for changes to public health policy in order to accommodate the vast numbers of seniors who will likely experience chronic care issues in the near future. Chronic diseases account for 70% of all deaths, 60% of health care costs, and 33% of deaths before the age of 65. Our health care system is not meeting the needs of those with chronic diseases; less than 30% of those with hypertension are being treated. Those with diabetes should have eye exams. Asthma is not controlled properly in 60% of our population. Sufferers of heart failure are readmitted at the rate of 20% within 60 days (Rachlis, 2006).

In The Hazards of Health Care (Heckman, 2004), warnings are given for undiagnosed dementia and delirium. We know what chronic disease does to our seniors. It reduces the quality of life for both victims and their families. There are fewer than 200 geriatricians in Canada (2003), and we need 600 to keep up with international standards for a country with our population. A Medscape article (2006) interviewed an author of a JAGS study (J. Am. Geriatr Soc. 2006;54:1453-1462), and he said,
"there are currently just under 200 geriatricians working in Canada compared with an anticipated need for between 512 and 607 geriatricians in 2006. With 4 to 9 residents entering a GM specialty training program each year, coupled with growth in the Canadian population older than 65 years and the projected retirement of many practicing geriatricians, the shortage will continue to worsen."

Ontario geriatricians say they cannot afford to practice. It is the lowest paid, and the least funded in Ontario.

What we need:

• More palliative care rooms
• More better trained staff with a wide range of expertise to manage chronic disease
• Family health teams that include PSWs, nurse practitioners, physician assistants, as well as physicians, to address issues and deliver a full range of care
• More funding for staff
• Requirements for in-service training of PSWs and medical staff, including nurses and physicians, in geriatric issues: physical and mental health issues that require specific treatments
• More continuity of care, with staffing levels that permit this to occur
• An ombudsman to assist families

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*TPAs (transfer payment agencies) make up for a large number of these institutions. This means that money is transferred to an agency, which has a Board of Directors, and monitors how and where our taxes are spent in caring for the young, the old, the incompetent, the incapacitated and disabled, our frail and vulnerable seniors, and those in psychological, social and emotional crisis.


References:
Barclay, L. (2006). Shortage of Geriatricians May Hinder Healthcare for Elderly, Retrieved online from http://www.medscape.com/viewarticle/544464

Check on Senior Care Urged: Both opposition parties say nursing-home neglect will be a big issue for aging electorate in Oct. 10 vote.. (Toronto Star, 2007)
Ombudsman renews call for oversight of hospitals and long-term ...(pdf report, 2008)
Ombudsman Finds Ministry Bound By Its Own Red Tape (Sept., 2005)
Rachlis, M. (2006). Seniors’ health: We can’t afford the future if we don’t repeat the past. Retrieved August 29, 2008, from www.coaottawa.ca/health_forum/DrRachlis.ppt.

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