Violence in our twilight years

 In a horrible story of husbands and wives facing health issues.

Police continue to search for details in stabbing death of woman, 82

 Ottawa man charged with killing wife at seniors' home 
Ian Flann wheeled into hospital room to hear charges 
CBC News Posted: Dec 28, 2011 2:48 PM ET

Ian Flann (82) was took his wife back and forth between doctors' appointments over the years and neighbours said Ian's health had recently deteriorated. After complications from surgery Doreen Flann (82) was moved into the Longfields Manor Retirement Home. Friends said Ian visited often, but the visits were tense because his wife was suffering from dementia and often couldn't recognize him. Unfortunately, many a retirement home cannot cope with dementia clients.


Revera Inc is a private company categorized under Extended Care Facility and located in Mississauga, ON, Canada. It was established in 2007 according to Manta.com. Current estimates show this company has an annual revenue of $995,013,120 and employs a staff of approximately 25,000. 

Longfields is owned by Mississauga-based Revera Inc., which has more than 250 facilities across Canada and the U.S. and serves about 30,000 clients.

Violence in long-term care is a terrible issue.

A CBC new article states: More than a dozen people have died violently inside Canadian nursing homes during the past decade.
That doesn't seem like a lot to me. Not that one is too many.

We need to look at the facts. Violence in long-term care (LTC) occurs frequently enough that there must be better training for those who may pose a risk to themselves and to others. Murder is not the norm. But those with dementia lose the ability to control their tempers. They may be frustrated and unable to communicate, have left their family and their home. Staff must be trained and must be given the tools (human, physical and financial) to help them do their work.

Nursing Home Violence  :  White Coat Black Art

 A study (see below) from Laval University published in 2005 found that more than one in five older residents at long-term care facilities act aggressively.

CBC News Investigation (2007) documented a rapid increase in violent attacks in nursing homes in that province. Between 2003 and 2006, the number of violent incidents among residents of long-term care facilities increased from 446 to 1,416.

Now, reported family violence in society has remained at 6%, according to Statcan for 2004 and 2009.


Younger Canadians were more likely to report being a victim of spousal violence than were older Canadians. Those aged 25 to 34 years old were three times more likely than those aged 45 and older to state that they had been physically or sexually assaulted by their spouse. Family violence against seniors tends to be lower compared to younger age groups. The rate for seniors in 2009 was less than half that for adults aged 55 to 64 and more than eight times lower than the rate for adults aged 25 to 34.

There is violence in many workplaces, especially when people are ill and vulnerable.

Hospital violence strikes nurses' aids the most

And the least trained bear the brunt of it all.

Nursing and hospital violence

A national survey of nearly 19,000 nurses found a staggering 29.6 per cent of nurses working in a hospital said they were physically abused by a patient over the past 12 months, according to the 2005 study done by the Canadian Institute for Health Information, Health Canada and Statistics Canada.

Take paramedics: A study of 1,381 paramedics 

• 26.1 per cent had been physically abused, with 92.3 per cent reporting that patients were responsible for these attacks.

A 2005 inquest into a double murder at the Casa Verde Nursing Home in Toronto produced 85 recommendations [PDF].

• Better behavioural assessments, specialized units for aggressive residents, more nursing care, training and funding.
• If a resident is placed in a nursing home and the resident turns out to "have a complexity of care, such as aggressive behaviours, that cannot be safely managed," there should be a mechanism in place to quickly transfer the resident to a facility that has the capabilities to care for the resident.

(In other words, staff must speak truth to power, and admit that they cannot cope with a particular client.)

• The Ministry of Health and Long-Term Care should fund specialized facilities, as an alternative to long-term facilities, to care for demented or cognitively impaired residents exhibiting aggressive behaviour. The facilities should be designed using the model of the Dorothy Macham Home at Sunnybrook and Women's College Health Science Centre to meet the physical and staffing requirements of these high-need residents. 

We need a continuum of care. No question. Severe cognitive impairment is a predictor of violence. Agressive behaviour occurs also with chemical and physical restraints. It is imperative that staff be highly trained in this area.

Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities

Philippe Voyer^1*, René Verreault², Ginette M Azizah¹, Johanne Desrosiers³, Nathalie Champoux⁴ and Annick Bédard⁵ BMC Geriatrics 2005, 5:13 doi:10.1186/1471-2318-5-13

Results
The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.

It's flu season!

It's funny, but on Facebook groups, people still debate flu vaccines.

Some claim being ill following the vaccine.

Is the vaccine safe?

This is the eleventh year that the seasonal flu vaccine is being offered to Ontarians as part of the Universal Influenza Immunization Program. Every year, the vaccine is manufactured in the same way. The World Health Organization (WHO) determines which three strains of the flu are likely to have the biggest effect on the population worldwide. In their laboratories, they produce new flu vaccine strains and provide them to the manufacturers for production.

For the 2010-2011 flu season, the vaccine protects against the following WHO-recommended strains:

• A/California/7/2009 (H1N1)-like strain (this is the pandemic strain from 2009)
• A/Perth/16/2009 (H3N2)-like strain, and
• B/Brisbane/60/2008-like strain.

This year’s seasonal vaccine is non-adjuvanted. An adjuvant is sometimes added to a vaccine (such as in last year’s pandemic H1N1 vaccine) to boost the body’s ability to create antibodies, thus requiring a smaller dose of the antigen, the active ingredient in the vaccine. An antigen was added to last year’s pandemic H1N1 vaccine to allow vaccine to be produced faster.

Health Canada plays a very important role in ensuring that the vaccine is safe.

Health Canada evaluates the quality, safety and efficacy of the vaccine that is provided by the manufacturers. Samples of the vaccine are tested in Health Canada labs to ensure consistency in manufacturing. After Health Canada approves the vaccine, the manufacturer then ships across Canada.

The Ministry of Health and Long-Term Care, along with public health units and the Public Health Agency of Canada monitor for adverse events throughout the flu season. The most common side effects from a flu shot are redness and swelling at the injection site.

Local Health Integration Network (LHIN) model

An excellent examination of the Local Health Integration Network (LHIN) model.

2007 Aging at Home: LHIN Community Engagement

This is a good read, you can judge by these snippets. Below are two other articles he has written.

LHINs at Five years – What Now?

John Ronson

About the Author

John Ronson is a founding partner of Courtyard Group, a global company with offices in Canada, the United States and the United Kingdom that is dedicated to transforming the healthcare system.

Trying to predict the future is always dangerous.  At the inception of Ontario’s Local Health Integration Networks (LHINs) Ronson wrote two pieces for Longwoods – “Local Health Integration Networks:  Will “Made in Ontario” Work?”  [1. Abstract below] and a commentary on an article submitted by the LHIN Chief Executives:  Integrated Health Service Plans:  From Planning to Action [2. Abstract below]. 

2007 LHIN Community Engagement Session

Ronson writes: Looking back five years, how did I do?  
And more importantly, how have LHINs done and where do we go from here?

 Form Follows Function 
So what should change? The adage “form should follow function” may be old, but that doesn’t make it wrong. In healthcare in Ontario (and in Canada generally) we have split different healthcare delivery functions across multiple different types of organizations and then are surprised when we get poorly integrated care delivery at very high cost! With the creation of LHINs we attempted to split the planning function from actual healthcare delivery but we left a massive Ministry bureaucracy in place and hundreds of individual and separately governed healthcare organizations for LHINs to attempt to coordinate. Plus we left some of the most important functions (primary care, prescription drugs, etc.) outside of the model completely.

1. Will “Made in Ontario” Work? Ronson, J. 2006. "Local Health Integration Networks: Will 'Made in Ontario' Work?" Healthcare Quarterly 9(1): 46-49.

Abstract

The Province of Ontario has belatedly followed the other nine provinces in moving to a form of regional healthcare governance structure with the introduction of the Local Health System Integration Act, 2005 ("Bill 36") in the Ontario Legislature on November 24, 2005. Bill 36 has received second reading and has been referred to a Legislative Committee for hearings early in 2006.

2. Integrated Health Service Plans:  From Planning to Action

Abstract

The recent creation of integrated health services plans (IHSPs) by Ontario's 14 regional local health integration networks (LHINs) is an impressive example of collaborative planning, well documented in the lead article. The list of potential areas for improvement in health and healthcare is a long one - and the IHSP process has identified them well. Unfortunately, excellent planning, while an important precursor, does not ensure implementation success. Moving from planning to action is where many well-designed strategies disintegrate.

Multiple dimensions of traditional healthcare power dynamics must be addressed as LHINs move from planning to implementation. The traditional power bases of hospitals and physicians, largely unthreatened in planning, will move to the forefront during implementation. The "command and control" nature of the Ministry of Health and Long-Term Care must also be neutralized if LHINs are to be successful. Action strategies must be adopted immediately or LHINs will be tempted to retreat to the refuge of yet more planning.

References

Osborne, D.E. and T. Gaebler. 1992. Reinventing Government: How the Entrepreneurial Spirit is Transforming the Public Sector. Reading, MA: Addison-Wesley.

Smart Systems for Health Agency, Ontario. 2006. Smart Systems for Health Agency: Operational Review Final Report, November 6, 2006. Toronto: Author. 

The prescription for long-term care (WindsorStar)

Seriously, one writer purports to have the answer?

This is the kid of fearmongering and bad press that keeps misinforming the public and creating the notion that our system is 'broken'. Most facilities are for-profit, 500/600 or so, at one point in my research, but many are doing a wonderful job. The media tarnish the image of those who work hard in such facilities. Individual citizens who disparage staff and facilities demean the people in many institutions that are working hard to improve standards, delivering services in a safe and timely manner.

This is what she wrote:
  The prescription for long-term care  (WindsorStar)
 What exactly has to happen in our Long Term Care facilities for change to happen? The Toronto Star has reported cases of horrendous abuse and people are rightfully upset, but our Health Minister Deb Matthews acts surprised. How long have health care workers in these nursing homes been reporting the deplorable working conditions that directly affect the vulnerable seniors they try to care for? Who has bred the environment? Is it a wonder these reports are coming to light?
 Read more 

The solution is to work one home at a time. Health Ministers come and go. They create policy to please constituents, but make little impact. The reason, I feel, is that individuals within the system interpret the policies wrong. Individual staff members are always going to include those who abuse their power, and it is the individuals we must target. Institutions are there for-profit, but if we do not report individual situations, nothing will be improved. Canadians have to stop being so nice.
How many complain in blogs or in the comments sections, make horrible claims, and target health ministers when they should target a staff member, a policy maker at the institutional level, or managers.

'The Toronto Star, in its investigation, found that residents in most for-profit nursing homes are limited to one diaper per shift'

 Firstly, there is little data to support this claim. Definitely, there are some report of such incidents, but they are hardly the norm. There are pockets of poorly trained PSWs, working in poorly run facilities. It is up to us to ensure that proper protocols are followed, whether we be staff, residents or family members.
Secondly, we do not call them diapers. Preferable is adult incontinence products. That is insulting to those in long-term care. Oh, yes. with the disappearance of group care, long-term care (LTC) houses those who require less nursing than a hospital.
Thirdly, family members and staff need to be reporting these incidents to either the authoritative body, or to the OPSWA.

Complaints about retirement homes

The Ontario Retirement Communities Association (ORCA) operates a toll-free Retirement Home Complaints Response and Information Service that provides seniors and their families the information they need to make informed choices and help resolve problems quickly and effectively.

This Service helps consumers address questions or concerns about any retirement residence in Ontario, including those that are not ORCA members*. This free service is funded by the Province of Ontario.

Call 1·800·361·7254 to reach an experienced Information Officer.

Important Notice

Reporting requirements under the Retirement Homes Act, 2010 (the “Act”) came into force on May 17, 2011. Under the Act, there is an obligation to make a report to the Registrar of the Retirement Homes Regulatory Authority (the “RHRA”) if you suspect any harm or risk of harm to a resident resulting from improper care, abuse or neglect, or unlawful conduct. There is also an obligation to report suspicions of misuse or misappropriation of a resident’s money. Residents may make a report, but the Act does not require them to.

To make a report, call the CRIS line at 1-800-361-7254

Complaints about LTC

You can report specific incidents at the MOH & LTC website. See making a complaint.
That said, you can make a complaint about an individual nurse on duty, or a physician. The Dr. only in the LTC home once per week. The nurses busy doling out meds. When I complained about one of my late father's physicians, I was quite pleased with the intervention on the part of the College of Physicians. They came into the LTC home, spoke to the Dr., gave him some advice, spoke to nursing staff, and similarly checked them out.

Find out more about :

• Residents' rights
• The ministry's regular inspections and reviews
• How the government enforces its standards
• What happens when you make a complaint
• How to make a complaint
• LTC Homes Reports

Canadian healthcare vs. US citizens who fight for care

The difference between Canadian and US healthcare. Canadians all put money into the healthcare pot.

Patients Want To Read Doctors' Notes, But Many Doctors Balk : NPR npr.org - Patients have the legal right to see their doctor's notes, but actually getting them can be slow and expensive. Two new surveys say patients overwhelmingly want to read the notes. But doctors are much more dubious about the...
Institute for Health Technology Transformation

My physician keeps his records on the computer and we look at it together. My visits to my doctor are free.

I realize that investigation a health issue may involve some trials and errors.
My last issue, a bought with poison ivy, was a huge mystery.

Eventually, we solved it.

This is the difference between our countries, and having universal healthcare. It isn't a battle to fight an insurance company for coverage for normal, common issues. Or fighting the US government. [Medicare denies a brain tumor drug after a patient moves] Or fighting US Medicare, for fair payments.

In the US, physicians can opt out of Medicare.
One writes:
I have talked some of my colleagues and some of my patients, and all of us are very upset about this. Some of my physician friends are really thinking this time about completing the necessary paperwork to stop accepting Medicare patients. How can any business (except government) run with such uncertainty as not finding a permanent fix to the broken current Medicare system. Patients will be unable to see their physicians, resulting in delayed care, increased hospitalization, and illness.

The patient reality of a Medicare payment cut

• AMA: Why patients should care about fixing the Medicare physician payment cut

*US Medicare: Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria. Medicare in the United States somewhat resembles a single-payer health care system, but is not. Before Medicare, only 51% of people aged 65 and older had health care coverage, and nearly 30% lived below the federal poverty level.

Canadian healthcare: Approximately 99% of physician services, and 90% of hospital care, are paid by publicly funded sources, whereas almost all dental care is paid for privately. Most doctors are self-employed private entities.
Government of Canada, Health Canada. "Canada Health Act - Health Care System - Health Canada.

We've come a long way!

Ontario healthcare is not broken, managers are ignorant

These are the kinds of stories that convince some that Ontario healthcare is broken. Fortunately, this is not the case.
This is illegal, and through Ontario Health Insurance Plan (OHIP) they cannot charge fees to this woman. The MPP, NDP Michael Prue, intervened, and the hospital admitted their mistake. The manager who sent the letter, demanding payment,

Hospital apologizes after ‘blackmailing’ stroke patient with $1,300 daily charges

“They made a mistake,” Health Minister Deb Matthews said Monday, hours after the hospital apologized to the family of 84-year-old Ruth Woodside for threatening to charge an illegal fee in a bid to get her out of the hospital and into a long-term care home.

This is not how it works in Canada. This hospital made a huge mistake.

The family followed the normal process for securing their mother a bed in LTC. Through Community Care Access Centre (CCAC) they chose two long-term care homes near-by and put their mom on a waiting list.

The hospital sent a terse letter saying they must choose three, despite the third being too far away for family to visit and monitor the care. Mrs. Woodside is on a feeding tube, having had a stroke.
The hospital manager demanded the family choose the third, or take her home, or pay $1300/day for care.

Senior LGBT couples as caregivers

This is a beautiful story of care, love and a 54-year relationship.
Senior caregivers show much devotion to one another. This is a beautiful love story.

Excellent advice for Alzheimer patient's caregivers

Here is a great resource:
Dealing with Dementia: 10 tips to help caregivers cope
In summary:

1. Become an information sponge
2. Don't take changes personally
3. Plan ahead
4. Listen to your loved one
5. Acknowledge your grief
6. Take people up on their offers of help
7. Connect with other caregivers
8. Watch your own health
9. Speak out
10. Find your joy

Giver yourself permission to take it easy. As I volunteer in PCCC, with quite a few residents with dementia, I can see the TLC that staff give to our loved ones. Many with Early Onset Dementia (EOD) are otherwise healthy, but exhibit behaviours loved ones find difficult to watch.

If you can understand that blood and oxygen are getting to the brain cells, and that this is a disease, try to disconnect, get help when you need it.

If you place a loved one in a residential facility, some may not understand why. Many will never understand. Let the guilt go.

I used to give myself permission to take a day off of visiting my dad. It wore me out.
For those who have loved ones at home, or in LTC, there are many things you can do with a loved one:

1. Do a life review
2. Go through photo albums
3. Many love their stuffed toys: the mechanical ones, for kids, have been a hit. Mine I bought for my grandchildren when they visit, but they make my LTC friends laugh with joy!
4. Find things that replicated hobbies, you can't golf any more, but most LTC have a Wii, and you can play sports Wii!
5. Cards, board games, magazine
6. Decorate their rooms with joy of past memories, or for the holidays.

My friend, in LTC, Art. I asked if I could take his picture with my dancing, singing rabbit. He said, 'Yes, as long as you don't show my wife!'

A former model, now a resident in my local LTC, loves looking through fashion magazine.
A former head nurse of the local hospital must find it odd being a care recipient.

Visit on a day when there is entertainment, many have musical guests, fun activities, find a calendar of activities and plan your visits around that.

Musical guests: Keen Like Mustard!

For those who may interact with people with dementia

1. Learn a little: Test Your Knowledge
2. Be kind, don't be afraid
3. Forget the Alzheimer's jokes
4. Give caregivers a break
5. Visit often, short visits: read about visitor suggestions

Medicare fault is a terribly misunderstood idea in Canada

For the most part, each province and territory runs things in their own way, with the federal government contributing money. Currently, the provinces and territories are renegotiating

We are at a crossroads, with a Prime Minister PM, who is determined to thrust legislation through parliament, despite many objecting to, for example, the new Crime Bill. Crime is down, legislation up. It's all optics, rhetoric, and 20-somethings in the PMO who drive the agenda.

The same is true with healthcare. Many claim that our system is broken. It captures headlines, yet doesn't reveal the truth. As in the USA, provinces and territories run their healthcare systems differently. To make these gross claims is just plain wrong. There are system deformities, for example, in a country where abortion is legal, provincial control ensures that women in PEI cannot access an abortion in their province. For those without the financial and emotional resources to go out-of-province, this is a huge barrier to care.

Examining Canadian healthcare truly must be undertaken on a province-by-province, and territorial basis. With the philosophy of universal healthcare in Canada, Concierge Healthcare in Calgary, Harper's former stomping grounds, is a shameful way to deliver two-tier, private care.

I have read a financial, economists point of view of healthcare, which misses what is going on in some parts of Canada. The healthcare accord between Canada and the provinces and territories comes up in 2014. Many of us are afraid of what PM Harper will do.
In the meantime, many lobby, subtly, for privatisation of healthcare, through claims that the healthcare system is broken. Other economists (truly!), are analysing what works, what needs changing.

CHAP  - Cardiovascular Health Awareness Program

How would Apple run medicare?
November 22, 2011-by William Watson, Ottawa Citizen.
What would the system would look like if it were run by Apple? Or Virgin? Or Amazon? Or any other...

This is a reiteration of one author's summaries by William Watson, Ottawa Citizen.
He regurgitates Don Drummond's C.D. Howe Institute Benefactors Lecture for 2011, which he delivered last week in Toronto on the subject: "Therapy or Surgery: A Prescription for Canada's Health System." For the full report (PDF)


Drummond believes that:

1. Primary care physicians should band together
2. Chronic-care patients (ALC) should be taken out of hospitals 
3. The system needs to re-orient from care to prevention
4. Paying doctors per service encourages them to perform too many services while paying a salary (see Concierge Healthcare out west) discourages efficiency. Drummond favours a 70% salary; 30% fee for services.

I find it interesting reading about such ideas, as if they are new...

Read labels: 'per1/6 tray' of cookies

1. Family health teams (FHT) abound in Ontario (200 to date). 
2. Long-term care is filled with those who can pay for the services, they are full, with waiting lists, unless you can afford a private room. In that case, ALCs get into retirement homes, or buy private services for better Home Care. Private transfer payment agencies draw nurses from public administration. 
3. The beauty of Nurse Practitioners, and the FHT, means that dietitians, RNs, social workers, and nurse practitioners can support the patient, give advice, provide workshops to those seeking to change their eating habits, monitor blood pressure, modify lifestyles. One of the best programs was CHAP, where you can learn about heart health and monitor your own health. But we all know how difficult it is to change. When I ran blood pressure clinics in Central Ontario, I found that many had learned about heart health. This was a terrific program that demonstrated much success.
4. I think that the fault in our system revolves around physicians who do not understand geriatrics, who cherry pick patients, who do not ascribe to new notions about palliative pain management  vs. chronic pain (see Self-governing body CPSO Pretty Lax; What is your physicians medical batting average?; Who is protecting patients?; WCBA -Before You Fire Your MD - Have a Chat -  The Role of Doctors in Opiod Use).

Health care's future on ministers' agenda
Canada's provincial and territorial health ministers meet with federal counterpart Leona Aglukkaq on Friday in Halifax to discuss the future of health care. more »

Self-governing regulating bodies pretty lax

Why is it that the College of Physicians and Surgeons of Ontario (CPSO) cannot do a simple Google search when renewing a licence for a physician?

In September 2008, Dr. Joyce Buckley had her New York State medical licence revoked for "gross negligence."


Gynecologist faces allegations of unprofessional conduct

November 28, 2011

Ontario's governing body for doctors alleges Buckley misled the college in April 2008 when she renewed her medical licence in this province.
The college says Buckley answered 'no' to the question: "Are there any disciplinary actions pending against you by a licensing authority other that the CPSO?"


A simple search found:
Watertown Daily Times | Watertown doctor's license revoked
22 Sep 2008 – Dr. Joyce Wong Buckley's medical license has been revoked, effective Tuesday.

When she went to the CPSO to have her licence renewed she lied to them.