1 enhancing compassionate care for the elderly: a systems perspective presented to: canadian...
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Enhancing Compassionate Care for the Elderly: A Systems Perspective
Presented to:Canadian Parliamentary Committee on Palliative and Compassionate Care
Presented by:
Neena Chappell, PhD, FRSC
Canada Research Chair, Social Gerontology
Professor, Centre on Aging and Department of Sociology
President, Canadian Association of Gerontology
and
Marcus Hollander, PhDPresident, Hollander Analytical Services Ltd.
Presented at: James Bay New Horizons November 9, 2010
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Introduction
• Research suggests that it is possible to simultaneously save money and provide better and more compassionate care.
• Based on our research, it is our view that policy makers should resurrect and re-validate Continuing Care as a major component of the Canadian health care system. That is, adopt a system specifically designed to provide seamless, high quality and cost-effective care to older adults with care needs, and their families.
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A Short History of Continuing Care in Canada
• Continuing care started in the mid 1970s in Manitoba and an integrated system of care was developed in BC between 1978 and 1983.
• By the mid-1980s the BC and Saskatchewan Ministries of Health had Executive Directors of Continuing Care.
• In the early 1990s some 7 provinces had, at various points in time, one person responsible for their provincial continuing care service delivery system. There was also a Federal/Provincial/Territorial Sub-Committee on Continuing Care which functioned from the mid-1980s to the early 1990s.
• Continuing care has been in decline since the mid-1990s
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The Emergence of the Continuing Care System
Acute Hospitals Public HealthGovernment and CharitableSocial Welfare Services
HospitalBased
GeriatricAssessment
andTreatment
Units
DayHospitals
ChronicCare
Hospitalsand
Units
LongTermCare
Facilities
GroupHomes
AdultDayCare
Centres
HomemakerServices
MealsPrograms
HomeNursing Care
Services
CommunityRehabilitation
Services
The Origins of the Continuing Care System(The Old System)
The Continuing Care Service Delivery System(The New/Emerging System)
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Previous System
Current System (National Policy Focus)
Hospitals Primary Care
Continuing Care
DrugsPopulation and Public
Health
Other Services (mental health,
Ambulance, etc.)
Hospitals Primary Care
DrugsPopulation and Public
Health
Other Services (long term residential care, home care, palliative
care, respite care, etc.)
• Continuing Care was, and would still be today if a system existed, the third largest component of public health expenditures after hospitals and primary care and, as such, deserves a greater policy focus.British Columbia Ministry of Finance and Corporate Relations. (1992). Estimates; Fiscal year ending March 31, 1993. Victoria, BC: Crown Publications; Hollander, M.J., Miller,J.A., MacAdam, M., Chappell, N., & Pedlar, D. (2009) Increasing value for money in the Canadian healthcare system: New findings and the case for integrated care for seniors. Healthcare Quarterly, 12 (1), 38-47.
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The Role of Home Care, Home Support and Unpaid Caregivers
• Unpaid, family caregivers provide an indispensable service to the health care system as home care only provides paid services to round out the care provided by family and friends. The annual financial contribution of unpaid caregivers 45 years of age or older, providing care to people aged 65+, has been estimated to be some $25 billion. Thus, family caregivers are a critical adjunct to our health care system and deserve to be supported. Hollander, M.J., Liu, G., & Chappell, N.L. (2009). Who cares and how much? The imputed economic contribution to the Canadian healthcare system of middle-aged and older unpaid caregivers providing care to the elderly. Healthcare Quarterly, 12(2), 42-49.
• In addition to being a stand alone service, home care (including non-professional home support services) can also be a vehicle, within an integrated system of care, to enhance value for money in our health care system through substitutions of lower cost care, for higher cost care, with equivalent or better outcomes.
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The Conundrum of Non-Professional Home Support Services
• People with ongoing care needs due to functional deficits have “health” problems and require “medically necessary” care. However, the “medically necessary” care services they require to maximize independence and minimize their rate of deterioration are, in large part, non-professional home support services. This does not seem to be recognized in the current policy discourse.
• Home support is a low cost alternative to residential care and hospital care for both the preventive and substitution functions of home care.Hollander, M.J. (2001). Evaluation of the Maintenance and Preventive Model of Home Care. Victoria: Hollander Analytical Services Ltd; Hollander, M.J., Chappell, N.L., Prince, M., & Shaprio, E. (2007). Providing care and support for an aging population: Briefing notes on key policy issues. Healthcare Quarterly, 10 (3), 34-45.
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• In the fall of 1994, a policy was put into place in British Columbia to cut Personal Care clients (those with the lowest care needs) who only received house cleaning services.
• Most cuts were made in the first half of 1995.
• Different patterns of response by Health Units (HUs) to the policy.
• Some HUs did not cut services, some cut moderately and some cut severely.
Cost-Effectiveness of the Preventive Function of Home Care and the Role of Home Support
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Period Year Prior
to Cuts ($)
First Year After Cuts
($)
Second Year After Cuts
($)
Third Year After Cuts
($) Cuts 5,252 6,688 9,654 11,903 All
Costs No Cuts 4,535 5,963 6,771 7,808
Per Person Average Costs of Care Before and After Cuts for Health Units With and Without Cuts
Source: Hollander, M.J. (2001). Evaluation of the Maintenance and Preventive Model of Home Care. Victoria: Hollander Analytical Services Ltd.
•A recent study by Markle-Reid also found that modest amounts of home support services may reduce hospital and LTC facility costs.
Source: Markle-Reid, M., Browne, G., Weir, R., Gafni, A., Roberts, J., & Henderson, S. (2008). Seniors at risk: The association between the six-month use of publicly funded home support services and quality of life and use of health services for older people. Canadian Journal on Aging, 27 (2), 207-224.
Comparative Costs
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Comparative Cost Analysis in 2000/2001 Dollars Including Out-of-Pocket Expenses and Caregiver Time Valued at Replacement Wages
Level of Care Victoria Winnipeg Community
($) Facility
($) Community
($) Facility
($)
Level A: Somewhat Independent
19,759 39,255 N/A N/A
Level B: Slightly Independent
30,975 45,964 27,313 47,618
Level C: Slightly Dependent
31,848 53,848 29,094 49,207
Level D: Somewhat Dependent
58,619 66,310 32,275 45,637
Level E: Largely Dependent
N/A N/A 35,114 50,560
Source: Chappell, N.L., Havens, B., Hollander, M.J., Miller, J.A., and McWilliam, C. (2004). Comparativecosts of home care and residential care. The Gerontologist, 44, 389-400.
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Comparative Cost Analysis for Community and Facility (Study 2)
Care Level
Total Client and Family Contribution
– Replacement Wage1
Total Costs to Government
for Paid Services
Overall Total2
Level 1 $11,594 $7,090 $18,684 Level 2 $14,175 $7,033 $21,208 Level 3 $18,135 $7,129 $25,264 Level 4 $22,111 $11,414 $33,525 Level 5 $74,139 $16,759 $90,898 Level 6 or higher $65,560 $12,904 $78,464
Community
Overall Average $22,753 $8,230 $30,983 Level 3 $14,246 $83,148 $97,394 Level 4 $18,288 $87,578 $105,866 Level 5 $19,332 $85,555 $104,887 Level 6 $22,779 $82,573 $105,352 Level 7 $30,953 $83,754 $114,707 Level 8 $32,830 $83,371 $116,201 Level 9 $30,402 $83,410 $113,812
Facility
Overall Average $26,682 $84,168 $110,850
1 These are the total of out-of-pocket expenses and caregiver contribution costed at replacement wages.2 These are the total of client and family contribution costed at replacement wage and costs to government.
Hollander, M.J., Miller,J.A., MacAdam, M., Chappell, N., & Pedlar, D. (2009) Increasing value for money in the Canadian healthcare system: New findings and the case for integrated care for seniors. Healthcare Quarterly, 12 (1), 38-47.
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• Yes, this was demonstrated by the BC Planning and Resource Allocation Model developed in 1989. There was a significant shift of clientele from residential care to home care, while the overall utilization rate remained relatively constant. The substitution of home care for residential care resulted in an annual cost avoidance of some $150 million per year by the mid-1990s.
• It is believed similar opportunities for cost-effective substitutions still exist. This is certainly the case based on VAC data.
Even If Home Care Is Cost-Effective, Is There Any Evidence That Savings Can Be Obtained In The Real World?
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1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Community 87.2 89.5 92 96.5 98.7 100.7 102.4 105.8 110.8 113.8 114.8 116.2 113
Homemakers 80.9 83.1 84.9 88.7 90.9 93.3 95.1 98.4 103 105.5 106.5 107.6 101.2 Residential 71.5 71.6 71.7 69.7 67.2 65.1 63 60.4 58.2 56.5 55.2 53.5 50.7 LTC Facilities 52.5 52.7 52 50.1 48.1 46.1 44 42.1 40.3 38.6 37.8 36.7 34.4 EC Hospital 18.9 19.1 19.7 19.6 19.1 19.1 19 18.3 17.9 17.9 17.4 16.9 16.3
Utilization rates per 1,000 population aged 65 and over by fiscal year and type of care.Fiscal year 1983 is for the period April 1, 1982 to March 31, 1983.
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Community 87.2 89.5 92.0 96.5 98.7 100.7 102.4 105.8 110.8 113.8 114.8 116.2 113.0
Homemakers 80.9 83.1 84.9 88.7 90.9 93.3 95.1 98.4 103.0 105.5 106.5 107.6 101.2
Residential 71.5 71.6 71.7 69.7 67.2 65.1 63.0 60.4 58.2 56.5 55.2 53.5 50.7
LTC Facilities 52.5 52.7 52.0 50.1 48.1 46.1 44.0 42.1 40.3 38.6 37.8 36.7 34.4
EC Hospital 18.9 19.1 19.7 19.6 19.1 19.1 19.0 18.3 17.9 17.9 17.4 16.9 16.3
Growth Phase,to 1983
Restraint and Consolidation,1983 - 1989
Planning Model,1989 - 1993
Regionaliza-tion 1994 onward
Major Phases In The Utilization Of Home Care & Residential Care
Source: Hollander, M.J., & Chappell, N.L. (2007). A Comparative Analysis of Costs to Government for Home Care and Long Term Residential Care Services, Standardized for Client Care Needs. Canadian Journal on Aging. 26 (SUPPL. 1), 149-161.
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International Findings
• Stuart and Weinrich in a 2001 study comparing Denmark (which has an integrated model of care and a strong reliance on home and community services) and the United States, found that from 1985 to 1997 per capita expenditures on continuing care for seniors increased by 8% in Denmark and 67% in the United States. Many of the efficiencies were achieved by increasing home care and reducing facility beds.
Source: Stuart, M., & Weinrich, M. (2001). Home- and community-based long-term care: Lessons from Denmark. Gerontologist, 41 (4), 474-480.
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International Findings (cont’d)
• Weissert, Lesnick, Musliner, and Foley in a 1997 American paper found that integrated systems with system wide case management, home care, residential care, and capitation funding, were more cost-effective (fewer admissions to long term care facilities) than regular, less integrated approaches. Source: Weissert, W. G., Lesnick, T., Musliner, M., & Foley, K. A. (1997). Cost savings from home and community-based services: Arizona's capitated Medicaid long term care program. Journal of Health Politics, Policy & Law, 22 (6), 1329-1357.
• Landi et al, in two Italian studies (1999 and 2001), showed that an integrated home care program reduced the rate of hospitalizations, and the number of hospital days and costs, in a before and after study. Source: Landi, F., Gambassi, G., Pola, R., Tabaccanti, S., Cavinato, T., Carbonin, P. U. et al. (1999). Impact of integrated home care services on hospital use. Journal of the American Geriatrics Society, 47 (12), 1430-1434.; Landi, F., Onder, G., Russo, A., Tabaccanti, S., Rollo, R., Federici, S. et al. (2001). A new model of integrated home care for the elderly: Impact on hospital use. Journal of Clinical Epidemiology, 54 (9), 968-970.
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A Framework for Integrated Care
• Integrated systems of care allow for the substitution of lower cost services for higher cost services, while maintaining the same, or a higher quality, of care.
• An international review of integrated models of care by Margaret MacAdam, a senior Ontario based health researcher and consultant, has indicated that the Hollander and Prince framework is currently a leading framework for organizing continuing care services.
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The Hollander and Prince Framework for Organizing Integrated Systems of Care for People with Ongoing Care Needs
Source: Hollander, M.J., & Prince, M. (2007). Organizing Healthcare Delivery Systems for Persons with Ongoing Care Needs and Their Families: A Best Practices Framework. Healthcare Quarterly, 11 (1), 42-52.
Philosophical and Policy Prerequisites
1. Belief in the Benefits of Systems of Care
2. A Commitment to a Full Range of Services and Sustainable Funding
3. A Commitment to the Psycho-Social Model of Care
4. A Commitment to Client- Centered Care 5. A Commitment to Evidence-Based Decision Making
Best Practices for Organizing a System of Continuing/Community Care
Administrative Best Practices 1. A Clear Statement of Philosophy, Enshrined in Policy 2. A Single or Highly Coordinated Administrative Structure 3. A Single Funding Envelope 4. Integrated Information Systems 5. Incentive Systems for Evidence-Based Management
Service Delivery Best Practices 6. A Single/Coordinated Entry System
7. Standardized, System Level Assessment and Care Authorization 8. A Single, System Level Client Classification System
9. Ongoing, System Level Case Management 10. Communication with Clients and Families
Linkages With Hospitals
1. Purchase of Services for Specialty Care
2. Hospital “In-Reach”
3. Physician Consultants in the Community
4. Greater Medical Integration of Care Services
5. Boundary Spanning Linkage Mechanisms
6. A Mandate for Coordination
Linkages With Other Social and Human Services 1. Purchase of Service for Specialty Services
2. Boundary Spanning Linkage Mechanisms
3. High Level Cross-Sectoral Committees
Linkage Mechanisms Across the Four Population Groups
1. Administrative Integration
2. Boundary Spanning Linkage Mechanisms
3. Co-Location of Staff
Linkages with Primary Care/ Primary Health Care 1. Boundary Spanning Linkage Mechanism 2. Co-Location of Staff 3. Review of Physician Remuneration 4. Mixed Models of Continuing/Community Care and Primary Care / Primary Health Care
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Figure 3: Application of the Framework to the Elderly
Acute CareHospital Services
Day Hospitals
Hospital-Based Geriatric Units
Short StayAssessment and
Treatment Centres
Residential Services
Group Homes
Assisted Living
Supportive Housing
Residential Respite Care
Residential Palliative Care
Hospital Services (stepdown care)
Chronic/Extended CareFacilities
Long-Term Care Facilities/Nursing Homes
Home-and Community-Based Services
Vertical and Horizontal Integration Through Case Management
Application of the Framework to the Elderly
Acute CareHospital Services
Geriatric Units
Short StayAssessment and
Treatment Centres
Group Homes
Assisted Living
Supportive Housing
Residential Respite Care
Residential Palliative Care
Hospital Services (stepdown care)
Chronic/Extended CareFacilities
Nursing Homes
Tertiary/Quaternary Care Level
Secondary Care Level
PrimaryCare Level
Meal Programs
Home Nursing Care
Home Support Services(Homemakers/Care Aides)
Adult Daycare/Support
System-Level Case Management
Community-Based Respite Care
Community-Based Palliative Care
Adult Foster Care
Physician Care Facilitators
Self-Managed Care Options
Home Based Rehabilitation Care
Specialty Transportation Services
Life/Social Skills Training and Support
Technical Aids, Equipment and Supplies
Community Emergency Services/Crisis Support
Figure 3: Application of the Framework to the Elderly
Acute CareHospital Services
Day Hospitals
Hospital-Based Geriatric Units
Short StayAssessment and
Treatment Centres
Residential Services
Group Homes
Assisted Living
Supportive Housing
Residential Respite Care
Residential Palliative Care
Hospital Services (stepdown care)
Chronic/Extended CareFacilities
Long-Term Care Facilities/Nursing Homes
Home-and Community-Based Services
Vertical and Horizontal Integration Through Case Management
Application of the Framework to the Elderly
Acute CareHospital Services
Geriatric Units
Short StayAssessment and
Treatment Centres
Group Homes
Assisted Living
Supportive Housing
Residential Respite Care
Residential Palliative Care
Hospital Services (stepdown care)
Chronic/Extended CareFacilities
Nursing Homes
Tertiary/Quaternary Care Level
Secondary Care Level
PrimaryCare Level
Meal Programs
Home Nursing Care
Home Support Services(Homemakers/Care Aides)
Adult Daycare/Support
System-Level Case Management
Community-Based Respite Care
Community-Based Palliative Care
Adult Foster Care
Physician Care Facilitators
Self-Managed Care Options
Home Based Rehabilitation Care
Specialty Transportation Services
Life/Social Skills Training and Support
Technical Aids, Equipment and Supplies
Community Emergency Services/Crisis Support
Application of the Framework to the Elderly
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Client Referral
Ineligible and Leaves System
Ineligible but is Referred to Other
Resources
Single-Entry Process
Eligible for Care and Assessment
Is Conducted
Development/Review of
System-Level Care Plan
Consultation with
Physicians
Client EntersCare System
ReassessmentReassessment
Client Leaves System
Referral to Health and Human
Services Outside the System
Hospital Services Including
Specialized Assessments
Home and Community
Care
Long Term and Chronic Residential
Care
Client Referral
Ineligible and Leaves System
Ineligible but is Referred to Other
Resources
Single-Entry Process
Eligible for Care and Assessment
Is Conducted
Development/Review of
System-Level Care Plan
Consultation with
Physicians
Client EntersCare System
ReassessmentReassessment
Client Leaves System
Referral to Health and Human
Services Outside the System
Hospital Services Including
Specialized Assessments
Home and Community
Care
Long Term and Chronic Residential
Care
A Schematic of Client Through the System of Care
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Conclusion
• It is the integration of medical, health, supportive, community and residential/institutional care into one system that is the essence of the continuing care model and is why it is such a good fit to the actual needs of people with ongoing care needs such as the elderly and people with disabilities.
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Suggested Policy and Program Changes
Continuing Care
• Re-validate continuing care as a major component of the Canadian healthcare system.
• Re-balance priorities between short term and long term home care.
• Re-validate the importance of home support services and make strategic investments in home support.
• Ensure that future Health Accords, or other agreements, focus on integrated care, not just home care.
• Adopt a classification system which classifies people according to their care needs, irrespective of the site of care (e.g., SMAF).
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Suggested Policy and Program Changes (cont’d)
Continuing Care
• Adjust Federal and Provincial data collection and reporting to better identify the public and private costs of Continuing Care services.
• Due to the complex nature of continuing care, establish a federal/provincial forum (Federal/Provincial/Territorial Advisory Committee Structure, Health Accord, new legislation, and/or Social Union Framework Agreement [SUFA]) to more fully develop integrated systems of continuing care and enhance value for money.
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Unpaid Caregivers
• Provide support for respite care;• Assess the needs of caregivers;• Provide information, resources and counseling for
caregivers;• Conduct demonstration and evaluation projects to
develop informed policy regarding direct payment to caregivers; and
• Adjust labour and tax policy to support caregivers.
Policy Prescription for an Aging Population (cont’d)