Transcript Document

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, PhD
President, Hollander Analytical Services Ltd.
Presented at: James Bay New Horizons
November 9, 2010
1
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.
2
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
3
The Emergence of the Continuing Care System
The Continuing Care Service Delivery System
(The New/Emerging System)
Hospital
Based
Geriatric
Assessment
and
Treatment
Units
Day
Hospitals
Chronic
Care
Hospitals
and
Units
Acute Hospitals
Long
Term
Care
Facilities
Group
Homes
Homemaker
Services
Adult
Day
Care
Centres
Meals
Programs
Government and Charitable
Social Welfare Services
Home
Nursing Care
Services
Community
Rehabilitation
Services
Public Health
The Origins of the Continuing Care System
(The Old System)
4
Previous System
Hospitals
Primary
Care
Continuing
Care
Drugs
Population
and Public
Health
Other Services
(mental health,
Ambulance, etc.)
Current System (National Policy Focus)
Hospitals
Primary
Care
Drugs
Population Other Services (long term
residential care, home
and Public
care, palliative care,
Health
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.
5
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.
6
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.
7
Cost-Effectiveness of the Preventive Function of
Home Care and the Role of Home Support
• 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.
8
Comparative Costs
Per Person Average Costs of Care Before and After Cuts
for Health Units With and Without Cuts
All
Costs
Cuts
No Cuts
Year Prior
to Cuts
($)
5,252
4,535
Period
First Year Second Year Third Year
After Cuts
After Cuts
After Cuts
($)
($)
($)
6,688
9,654
11,903
5,963
6,771
7,808
Source: Hollander, M.J. (2001). Evaluation of the Maintenance and Preventive Model of Home Care.
Victoria: Hollander Analytical Services Ltd.
•A recent study by Markle-Reid also found that modest amounts of home support
services may reduce hospital and LTC facility costs.
Source: Markle-Reid, M., Browne, G., Weir, R., Gafni, A., Roberts, J., & Henderson, S. (2008). Seniors at
risk: The association between the six-month use of publicly funded home support services and quality of life
and use of health services for older people. Canadian Journal on Aging, 27 (2), 207-224.
9
Comparative Cost Analysis in 2000/2001 Dollars Including Out-ofPocket Expenses and Caregiver Time Valued at Replacement Wages
are
fC
evel o
L
eg
ip
n
in
W
ria
icto
V
ity
n
u
m
m
o
acility C
ity F
n
u
m
m
o
C
($)
($)
($)
acility
F
($)
t
en
d
en
ep
d
atIn
h
ew
m
o
:S
evel A
L
19,759
39,255
/A
N
/A
N
t
en
d
en
ep
d
tlyIn
h
lig
:S
evel B
L
30,975
45,964
27,313
47,618
t
en
d
epen
tlyD
h
lig
:S
evel C
L
31,848
53,848
29,094
49,207
t
en
d
en
ep
atD
h
ew
m
o
:S
evel D
L
58,619
66,310
32,275
45,637
/A
N
/A
N
35,114
50,560
t
en
d
epen
elyD
arg
:L
evel E
L
Source: Chappell, N.L., Havens, B., Hollander, M.J., Miller, J.A., and McWilliam, C. (2004). Comparative
costs of home care and residential care. The Gerontologist, 44, 389-400.
10
Comparative Cost Analysis for Community and Facility (Study 2)
Care Level
Community
Facility
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6 or higher
Overall Average
Level 3
Level 4
Level 5
Level 6
Level 7
Level 8
Level 9
Overall Average
Total Client and
Family Contribution
– Replacement
Wage1
Total Costs to
Government
for Paid
Services
Overall Total2
$11,594
$14,175
$18,135
$22,111
$74,139
$65,560
$22,753
$14,246
$18,288
$19,332
$22,779
$30,953
$32,830
$30,402
$26,682
$7,090
$7,033
$7,129
$11,414
$16,759
$12,904
$8,230
$83,148
$87,578
$85,555
$82,573
$83,754
$83,371
$83,410
$84,168
$18,684
$21,208
$25,264
$33,525
$90,898
$78,464
$30,983
$97,394
$105,866
$104,887
$105,352
$114,707
$116,201
$113,812
$110,850
1 These
2
are the total of out-of-pocket expenses and caregiver contribution costed at replacement wages.
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.
11
Even If Home Care Is Cost-Effective,
Is There Any Evidence That Savings
Can Be Obtained In The Real World?
• 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 mid1990s.
• It is believed similar opportunities for cost-effective
substitutions still exist. This is certainly the case
12
based on VAC data.
Major Phases In The Utilization Of Home Care & Residential Care
120 .0
Growth Phase,
to 1983
Regionalization 1994
onward
Planning Model,
1989 - 1993
Restraint and Consolidation,
1983 - 1989
100 .0
80.0
60.0
40.0
20.0
0.0
C ommu ni ty
H ome make rs
R esi de ntia l
LTC Fa cil itie s
EC H os pita l
1983





Community
87.2
87 .2
80 .9
71 .5
52 .5
18 .9
1984
89.5
89 .5
83 .1
71 .6
52 .7
19 .1
92 .0
84 .9
96 .5
88 .7
198571 .7
1986
69 .7
52 .0
96.5
19 .6
92 19 .7
50 .1
98 .7
90 .9
67 .2
48 .1
19 .1
1987
98.7
10 0.7
93 .3
65 .1
46 .1
19 .1
1988
100.7
10 2.4
95 .1
63 .0
44 .0
19 .0
1989
102.4
10 5.8
98 .4
60 .4
42 .1
18 .3
1990
105.8
11 0.8
10 3.0
58 .2
40 .3
17 .9
1991
110.8
11 3.8
10 5.5
56 .5
38 .6
17 .9
1992
113.8
11 4.8
10 6.5
55 .2
37 .8
17 .4
1993
114.8
11 6.2
10 7.6
53 .5
36 .7
16 .9
11 3.0
10 1.2
1994
199550 .7
116.2
11316 .3
34 .4
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 fis cal year and type of care.
Fis cal year 1983 is for the period April 1, 1982 to March 31, 1983.
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.
13
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.
14
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.
15
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.
16
The Hollander and Prince Framework for Organizing Integrated Systems of Care
for People with Ongoing Care Needs
Best Practices for Organizing a System
of Continuing/Community Care
Linkage Mechanisms Across the Four Population Groups
1. Administrative Integration
Administrative Best Practices
2. Boundary Spanning Linkage Mechanisms
Philosophical and Policy
Prerequisites
1. Belief in the Benefits of
Systems of Care
1. A Clear Statement of Philosophy, Enshrined
in Policy
2. A Single or Highly Coordinated Administrative
Structure
3. A Single Funding Envelope
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 ClientCentered Care
5. A Commitment to
Evidence-Based Decision
Making
4. Integrated Information Systems
5. Incentive Systems for Evidence-Based
Management
3. Co-Location of Staff
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
Service Delivery Best Practices
5. Boundary Spanning Linkage Mechanisms
6. A Single/Coordinated Entry System
6. A Mandate for Coordination
7. Standardized, System Level Assessment and
Care Authorization
Linkages with Primary Care/ Primary Health Care
8. A Single, System Level Client Classification
System
9. Ongoing, System Level Case Management
10. Communication with Clients and Families
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
Linkages With Other Social and Human Services
1. Purchase of Service for Specialty Services
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.
2. Boundary Spanning Linkage Mechanisms
3. High Level Cross-Sectoral Committees
17
Figure 3:
Application of the Framework to the Elderly
Application of the Framework to the Elderly
Acute Care
Hospital Services
Day Hospitals
Hospital-Based
Geriatric Units
Tertiary/Quaternary Care Level
Short Stay
Assessment and
Treatment Centres
Residential Services
Group Homes
Assisted Living
Supportive Housing
Residential Respite Care
Residential Palliative Care
Hospital Services
(stepdown care)
Secondary Care Level
Chronic/Extended Care
Facilities
Long-Term Care Facilities/
Nursing Homes
Home-and Community-Based Services
Meal Programs
Home Nursing Care
Home Support Services
(Homemakers/Care Aides)
Adult Daycare/Support
Adult Foster Care
Physician Care Facilitators
Self-Managed Care Options
Home Based Rehabilitation Care
Specialty Transportation Services
System-Level Case Management
Life/Social Skills Training and Support
Community-Based Respite Care
Technical Aids, Equipment and Supplies
Community-Based Palliative Care
Primary
Care Level
Community Emergency Services/Crisis Support
Vertical and Horizontal Integration Through Case Management
18
A Schematic of Client Through the System of Care
Client Referral
Ineligible and
Leaves System
Single-Entry
Process
Ineligible but is
Referred to Other
Resources
Eligible for Care
and Assessment
Is Conducted
Referral to Health
and Human
Services Outside
the System
Development/
Review of
System-Level
Care Plan
Consultation
with
Physicians
Client Enters
Care System
Long Term
and Chronic
Residential
Care
Hospital Services
Including
Specialized
Assessments
Home and
Community
Care
Reassessment
Client Leaves System
Reassessment
19
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.
20
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).
21
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.
22
Policy Prescription for an Aging Population
(cont’d)
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.
23