The Promise and the Realities

A SALT Paper By Carol Wodak on the Crisis in Long Term Care in Alberta, 2008/02/20

Promises (2000) and The Reality (2008)


Promise 1: Publicly funded health care services will be delivered as needed, whether the person was in their own home, supportive housing, or in a facility, through a process called ‘unbundling’; services will be coordinated to match the care to the needs of the person in any setting, so people will have choices. This a great idea – and it works well, in Denmark. There, the community care is comprehensive, coordinated, available, and publicly funded. (We bought into the American version of the Danish system.)
But the fine print in the Broda reports was really focused on a different goal: Albertans will be healthy, and will be responsible for their own health – and health care, if they’re foolish enough to be chronically ill – so continuing care will be ‘sustainable’ (that means, not publicly funded).
Systematic underfunding, promises instead of service delivery, delegating responsibility to individuals and the private market-place, deskilling the workforce, and cutting funding for slew of “unbundled” care services and products haven’t worked for us.
What we have is not comprehensive, coordinated, available, and publicly funded health care. ‘Choice’ and ‘Aging in Place’ mean you find and you pay.
It’s rather like Lego – if you buy the right pieces, and have the capacity and skills to put it together, you may end up with what you need.
It’s Do It Yourself healthcare. It doesn’t work for most folks.
Promise 2: Care services and housing will be affordable and accessible in a timely manner. Anyone who has needed either care or affordable housing knows that it’s not there when you need it and it’s not affordable. If you need both, as many seniors do, you know about desperation.
Facility fees have nearly doubled, to recover the cost of everything except specified nursing care – and it is being ‘unbundled’ in bits and pieces and reclassified as non-nursing care.
With private housing-and-care, it’s a smorgasbord, for which you can arrange for and pay separately for every service. This is, indeed, a growth industry for developers and operators, with public funding for capital costs, public rent subsidies, and operating contracts helping their bottom line. They like the unregulated rents and no specified care standards, too.
Promise 3: Home care services will be expanded, and supports will be provided for family and other informal caregivers. Actually, public home care services have been reduced, and increasingly rationed. We’re told the government is spending more than before on home care, probably because so many folks need post-acute home care and because the population has increased – and possibly because of private service providers, who need to make a profit.
Home care staff is poorly paid, so there staffing shortages and high turnover rates.
Integrated care programs, day programs and respite are in short supply.
Most elder care is provided by informal caregivers, who have few emotional or financial supports, which helps to make the system ‘sustainable’ (you pay).
Promise 4: Supportive housing settings with expanded care services will provide an alternative to institutionalization for folks who just need some assistance. There is a need for care between independent living and a nursing home; this is another good idea from Denmark.
The reality is that these ‘settings’ are being used to replace nursing home care with much lower levels of care (and in fact, many are ‘institutional’ in nature even if they look nicer).
Folks who just need a little assistance to live independently get ‘choice’, with a bill at the end of the month.
Promise 5: Care centres will be regenerated to provide care for persons with high and complex care needs – and particularly for persons with dementia illnesses or mental health illnesses. There are fewer care centre beds than in 2001 – and with our increasing population, even more seriously ill and impaired people who need skilled nursing care.
Most care services are now provided by untrained staff, without adequate monitoring and assessment skills. Increasingly, this care is provided according to a pre-determined schedule, rather than need. Restorative and rehabilitation therapies are seldom available.
As many as 80% of care facility residents have a diagnosis of dementia, but few facilities have staff with the expertise or the time to provide appropriate care, so there is significant reliance on sedation to reduce care needs.
Most 4-bed wards have been renovated to private rooms – but it does further reduce the number of beds. New care centres which replace older ones usually have fewer beds – or are built as assisted living facilities, offering less care.
Promise 6: The supply of both professional and other health care workers, with appropriate skills and knowledge, will be increased. Care centre beds are being closed because of staffing shortages. The job posting lists grow by the day, while the work force heads for better paying, easier jobs elsewhere.
The promise that Care Aides would have formal training or a demonstrated equivalency by March, 2008 has simply evaporated; the regional college training spaces are empty. The $13 an hour wage isn’t worth a huge investment in training - especially for a part-time or casual job.
Nurses are being used as administrators, and the new information and assessment systems take even more of their time from the residents. Maybe that’s why the ‘hours of care’ are defined as paid time, rather than time when care is actually delivered to people.
Alberta is remarkably slow to recognize that nurse practitioners have an important role in the complex care of seniors, and also fails to provide an appropriate role and adequate compensation for facility medical directors and attending or on-call physicians for time-intensive geriatric care. There are few geriatricians, and physician training pays little attention to the special care needs of seniors.

Prepared by Carol Wodak for SALT February 2008
(780) 417-1705 cwodak@techwcs.comThe Promise and The Reality, Appendix A: By the Numbers

1. 20 years of reform for Alberta Long Term Care

1988 2000 2007
Alberta Population 2,400,000 2,900,000 3,436,000
Ratio LTC beds/1,000 population 75+ 105/1,000 (1998) 86/1,000 (2006) 67.3/1,000
LTC Residents ~ 13,000 ~13,000 12,551
Calgary Herald Dec 17 2006: The government estimates 910 adults under age 65 - live in long-term care
Residential Care bed change, 2001 - 2004, -12.5%; change in population 75+, 2001–2004, 11.7%
Urgent placement wait list, average for year /as of March 31 522 713
666
Residents over 85 years (1990) 48% (2003) 49%
Residents in 3 (of 7) highest care needs categories 10% 68% n/a (2004) 70%
Residents with dementia diagnosis 33.9% (2003) 75%
Resident fees ($ per day; SP = semi-private, P = private room) (1990 SP $16.50
P $20.25) (1994) SP $26.25
P $28.60 SP $44
P $50.75
Before 1988: Resident fees fixed @30% of federal old age pension; co-pay to offset rent
Facility ownership (2001 14,486 beds*) (2006 14,468 beds*)
Public n/a 46% 38%
Voluntary n/a 25% 27%
For-profit n/a 29% 35%
Supportive Living Units n/a (2002) 8,005
(Public Lodges) 23,545
(incl. Lodges)
2. What 3.4 hours per resident per day looks like:


30 minutes –morning: toilet, mouth care, wash, dressing 15 minutes – help with lunch (again, 3 - 4 people) 5 minutes – medication administration
5 minutes – medications,
10 minutes – 2-person transfer into chair 15 minutes – 2-person continence care or toilet, transfer /lift to bed for nap 15 minutes – lift onto bed, 2- person continence care or toilet
15 minutes –breakfast (each caregiver assisting at least 3 residents) 10 minutes – check on resident several times; provide fluids, snacks 15 minutes – bedtime mouth care, wash, make comfortable in bed
15 minutes – assist with toileting (2-person transfer) 10 minutes – 2-person transfer/lift to wheelchair 10 minutes – late evening check and care
10 minutes – help finish off getting ready for the day 15 minutes –assistance with dinner 10 minutes – nighttime care and comfort
In a 2000 newsletter, the Bethany Care Society published a 24 hour care schedule for a dependent resident (total, 205 minutes, 3.42 hours). The chart was part of an article explaining that the Calgary Health Region had reduced care staff funding from 3.09 hours to 3 hours..
The article noted that a great many every-day needs (portering to a church service, going outside for a while, talking about family) weren’t included; and the 3 hours of funded care were expected to include: care management ( physicians’ medication orders, care conferences, care assessment and planning, calling family to update them on changes, charting, organizing appointments and transportation, etc.); clinical care and therapies (wound care, insulin, swallowing assessment, exercise/rehabilitation, recreation activity, social work support, pain; control, palliation and address unpredictable changes in clinical status); staff vacations, sick time, holidays and other leave.
(Source: author’s files)

3. Private Nursing and Home Support Care is Expensive.



Private Nursing and Home Support: A variety of services can be contracted from private home support agencies in order to help individuals and families in their home. These services would be paid for by the individual and/or family and may include professional nursing or home support services such as personal care, companion or respite care, homemaking (meal preparation, cleaning, etc.) and child care. Approximate Cost:
Registered Nurse: $50 per hour
Licensed Practical Nurse: $35 per hour
Community Support Worker: $20 per hour
Insurance Extended Health Benefits Insurance may pay some private nursing benefits.
(from Calgary Health Region Community and Supported Living Options: Information for Clients and Families, 2007)


Typical Resident Care Staff Wages (Feb 2008)
Registered Nurse: $29.33 - $38.50/hr (9 step grid)
Licensed Practical Nurse: $17.55 - $19.94/hr (5 step scale)
Care Guide $13.48 - $23.45/hr (5 step grid)
http://www.capitalcare.net/careers/nursing.html Feb 16, 2008
Community Home Support Worker: $11.82 – 16.73/hr (5 step grid)
Resident Companion $11.98 - $13.70/hr (5 step grid)
http://www.capitalcare.net/careers/resident_care.html

CEO, Capital Health: $880,000 (Calgary Herald June 27, 2007); with a 17% pay hike, $538,000 (Edm Sun March 18, 2006); $475,000 (2002,UNA news, Sept 2003)



4. The shift from facility care to assisted living settings in East Central Alberta
East Central Health Annual Report 2005/06
Vegreville: converting 90 long term care (LTC) spaces to 60 heavy complex care units.
Construction is underway and will be complete July 2007.
Vermilion: converting 65 LTC spaces to 48 heavy complex care units and are reviewing tender and will award the contract by July 2006.
Wainwright: converting 69 LTC spaces to 44 heavy complex care units and 40 DSH units
Lloydminster (Dr. Cooke Extended Care Centre): replacing 55 LTC spaces with 60 heavy complex care units.
East Central Annual Report 2004-05
Camrose: The Bethany Group replaced 188 LTC beds with 100 Facility care beds (long term care), 30 Flex beds (facility/supportive housing), 78 Supportive housing spaces.
Vermilion: Planning is underway for the replacement of the aging, 65-bed Alice Keith Nursing Home with a new, 48-bed long term care facility on the same site.
Vegreville: Replacing 90 long term care beds with 60 long term care beds and 40 supportive housing spaces.
Wainwright: will develop 40 supportive housing spaces and reduce 25 of the 67 long term care beds.

5. The care cost difference between facility care and Designated Assisted Living
Summary Chart, Hinton Mountain View Centre Conversion from Care Centre to DAL Jan 2008

Continuing Care Centre
(nursing homes) Designated Assisted Living
(‘Designated” means spaces under contract to Regional Health Authority)
Resident Fees Regulated by province Controlled by contract between operator and RHA
Accommodation Subsidy Available through Alberta Seniors Benefits; income tested, must apply.
(Changed in 2006 re grandfather arrangements)
Nursing Care 24/7 on-site RN and LPN
RNA supervision of LPN and Care Aide staff.
Rehab Assistant on-site 24/7 available (off-site, on call; may be provided by home care, operator or contracted agency)
LPN on-site during daytime hours
Rehab assistant only on-site
Personal Care 24/7 on-site
RNA supervision May be provided by Home Care on a scheduled basis. Controlled by contract with RHA; may be available on a fee-for-service basis
Call system Call system provided. Call system (Telecare) Mixed; some must pay for phone to access.
Prescriptions Supplied by Centre as needed. Resident responsible for providing, and for costs not covered by Alberta Seniors Drug Plan. Costs often higher than RHA bulk purchasing, special packaging increases costs.
Medical supplies and equipment Supplied by Centre; specialty items resident responsibility (AADL may be available) Resident responsible; some items may be eligible for subsidy through Alberta Aids to Daily Living (AADL)
Medically required Transportation Supplied by Care Centre. Resident responsibility
Personal Care Supplies Supplied by Centre Resident responsible
Personal Grooming Supplies Resident responsible; dentures, eyeglasses: Resident responsible; Seniors benefits may apply
Room Furnishings, bedding, towels Supplied by Centre; resident may replace with own furnishings. Resident must provide.
Food Services 24-hour; tray service in room if required; snacks and fluids. Uncertain. Additional charge for tray service to room.
Sources: Missing Pieces of the Shift to Home and Community Care: A Case Study of the Conversion of an Alberta Nursing Home to a Designated Assisted Living Program; Wendy Armstrong, Raisa Deber, PhD. 2006 ; 2008 updates from Ron and Lynda Jonson.

6. Examples of Private Assisted Living Optional Care Service Fees


Assisted Living Optional Care Service fees/month
(subject to GST) Holy Cross Columbia
Medication assistance $300 $50.00
Medication reminder $175 -------
Resident night Checks $175 -------
Meal Escort (3 meals/day) $300 $270
Meal Escort (2 or less/day) $175 -------
Daily Tray Service $300 -------
Meal Time reminder $175 -------
Meal assistance ------- $360
Daily light housekeeping $300 -------
Weekly personal laundry $50 $35
Support stocking assistance $250 -------
Dressing, am or pm, 15 minutes per ------- $270
Incontinence management $300 -------
Toileting, 10 minutes ------- $90
Bath assist (one/week) $100 $9.00 per bath
Bath assist (two/week) $175 -------
Extra assistance $350 -------
Holy Cross Manor, Calgary; data from website (service rates no longer posted on site)
Studio Apartment from $1945.00, One Bed room Apartment from $2445.00 per month (2008)
Additional resident $750.00 per month. Seniors feel rent squeeze at Holy Cross Manor (Calgary Herald, Mar 1, 2007). . . rents are being boosted by up to 40 per cent June 1. . . The cost for a one-bedroom apartment is expected to jump about a third, from around $1,800 to roughly $2,400 a month.
Columbia Assisted Living, Lethbridge; (data from website)
Studio Suite (380 sq. ft.) $1585, One Bedroom Suite (550 sq. ft.) $1895 per month
Additional resident in suite $600 per month; resident parking $20 per month

7. Funding announced for new long term care beds (resident & bed data from various AHW documents)

1998 LTC residents: 12,880
LTC beds: 14,396 Capital Health reopened 24 extra long-term care beds at the Edmonton General in late January, trying to take pressure off the system. The province has announced 600 new long term care beds over the next three years because of the shortages identified.
2000 Residents: ~13,000
LTC beds 14,226 beds
2002
2004 LTC residents 12,732
LTC beds ~14,300
2008 LTC residents 12,551
LTC bed count 14,468 Stelmach is promising to spend $300 million to open 600 new, long-term-care beds.
7 (a )

2000 Bethany Group plans 200 new continuing care spaces (130 continuing care, 70 supportive living spaces). The new facilities will replace 188 spaces in the Bethany Long Term Care Centre and the Hawthorne wing of the Rosehaven Care Centre.28
2005 New Kipnes Centre for Veterans’ (120 beds) opens. Mewburn Centre (140 beds) closes.

7 (b)

$300 million for 7 new Facilities, hundreds of LTC beds (29 Jan 2008 Government news release)
Project from Backgrounder History
Calgary Garrison Green Care Centre (supplementary funding) 200-bed long-term care facility
$125 million Jan 2005, Intercare will build 191 beds at Garrison Green; Feb 2005 CHR buys GG land for $4m from Intercare. Nov 2005, project shelved. Aug 2007: total cost was $62m, escalated to $70m; 191 beds for disabled young and frail elderly.
CHR LTC beds 2001: 4,583; 2006: 4,550 +100?

Didsbury, (supplementary funding) 60-bedLTC facility to replace the older 50-bed wing Planned in 2005, 2006 +10?
Strathmore, new 100-bed LTC facility (supplementary funding) to replace the older existing 23-bed wing Planned 2005, 2006; completion by 2007
P3 planning for ‘community of care” includes the relocation of (23) long term care units out of the hospital.
Dec 05 –Feb 06, RASL $1.35 million to Brenda Stafford Foundation Ltd; Supportive Living Beds Strathmore $1.35m (45 beds) +22?
Capital Health will add 300 new transition and support beds at Alexandra/Glenrose/Norwood 2006: Announced Transfer of Chronic Ventilator Unit to a specialty Continuing Care Centre (Norwood) to open 2010.
Of the 1400 residents in 11 CapitalCare LTC centres, 168 are specialty beds (2007)
Capital Health LTC beds: 2001, 4,644; 2006, 4,686 0
Capital Health/Good Samaritan Society; replace 70-bed LTC facility in Stony Plain. Replace 1968 care centre, should begin by 2005 ( GSS Annual Report 2004). GSS website 1/30/08:
Currently in the design phase +10?
Lloydminster, Dr. Cooke Extended Care Centre , new 60-bed LTC facility to replace the 55-bed nursing home wing Proposed 2007.
East Central Health Annual Report 2005/06: Lloydminster (Dr. Cooke Extended Care Centre): replacing 55 LTC spaces with 60 heavy complex care units; $4,335,762 RASL funding, Jan 2006). ECH has converted 279 LTC spaces to 212 Designated Supportive Housing units. +5?

Lacombe Continuing Care Centre; 2 4-bed rooms replaced with 12-bed dementia cottage
$10 million; no dates + 4?
Alberta Seniors Business Plan 2007-10: To support the shift to supportive living from long-term care settings, the Ministry encourages the development of affordable supportive living projects for seniors and persons with disabilities through approved capital funding. continuing-care waiting lists, including people who are not in acute-care wards, have risen to 481 names from 426 a year earlier and 270 two years earlier 151