Enhancing Compassionate Care for the Elderly: A Systems Perspective

1. 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 Enhancing Compassionate Care for the Elderly: A Systems Perspective

2. 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.

3. 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

4. The Emergence of the Continuing Care System

5. Previous System Population and Public Health Other Services (mental health, Ambulance, etc.) Primary Care Continuing Care Hospitals Drugs Current System (National Policy Focus) Other Services (long term residential care, home care, palliative care, respite care, etc.) Population and Public Health Primary Care Hospitals Drugs • 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.

6. 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.

7. 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.

8. 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.

9. Comparative Costs 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.

10. Comparative Cost Analysis in 2000/2001 Dollars Including Out-of-Pocket Expenses and Caregiver Time Valued at Replacement Wages 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.

11. 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.

12. 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 mid-1990s. • It is believed similar opportunities for cost-effective substitutions still exist. This is certainly the case based on VAC data.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. Application of the Framework to the Elderly

19. A Schematic of Client Through the System of Care

20. 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.

21. 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).

22. 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.

23. 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.