Chapter 12: Long-term care

Long-term care

>90% In-home assistance & Retirement Homes

Not just for elderly

Types of LTC and costs

Public is cheaper, but longer line

AL and private are so exp

Any institutional care > homecare

Who gets long-term care

Most are >65. Younger than that are 7% are either MS or spinal cord injury

Independent Living → Home Care → Assisted Living → Hospitalization → Rehab → Nursing Home → Hospice.

Aging popul is growing

⅓ lives in collective dwelling (ex. nursing home)

Family caregivers

More unpaid fam caregivers (mostly women) give LTC

LTC funding

not covered under the Canada Health Act.

universal public insurance plan is recommended

Public (75%) and private (25%) sources

Canada spends less on publicly funded LTC than most OECD nations

Home Care

Home care and community-based services are the broad array of medical and social services that are available to people who are still living in their own homes and that are provided by health care professionals, paid caregivers, and volunteers

25% of >65y/o are receiving home care

Most seniors who receive care rely on informal support, especially for practical tasks like housework and transportation

Benefits of home care

Maintained sense of identity

Maintained sense of control & autonomy

Familiarity of surroundings & community

Prevention or delay of institutionalization

Cost effective

Who frequently use government funded home care

Single, low income, physical limita, had a recent hospitalization

Alternate Level of Care (ALC) patients

Stuck in hospitals due to lack of long-term care beds in nursing homes, despite no longer needing acute care

Adult day program

Older adults who need assistance or supervision during the day receive a range of services in a setting that’s either attached to another facility, such as a nursing home, or stand-alone agency. May fall into category of respite care

Assisted (supported) living

provide government regulated housing with a supportive environment (hospitality & personal care services, not required nursing skills) to adults who ...

• Have physical and functional health challenges.

• Can live independently (but not unaided)

• Can make decisions on their own behalf

Three ideal attributes of assisted living facilities include

Physical space has a residential appearance/feel (private bathroom, garden, etc.)

Care provided to promote normal lifestyle of resident

Meeting residents’ routine services and special needs

• Assistance with Activities of Daily Living

• Meal provision

• 24 Hour assistance if necessary

Well-being after transition

Greater control over transition

Design of facility and services optimizes person/envi fit

Live in smaller sized facilities

Positive co-resident relationships

Had co-residents with similar levels of functioning

Few other residents with high levels of frailty

Frequent family contact

Moving from a hospital or other AL facility (ie. not from home)

Nursing homes

Gov regulated type of medical institution that gives a room, meals, skilled nursing and rehabilitative care, medical services, and protextive supervision

Residents have multiple health conditions and/or moderate/severe cognitive impairment (dementias), Often extremely frail – usually the last option

Residents often need help with cognition, hygiene, continence, mood, nutrition, and more.

61% take 10+ medications; 86% need extensive help with ADLs (eating, toileting, etc.).

Temporary residents include those recovering from major injuries, illness, or surgery

Factors that can increase this sense of “home” in nursing homes

Individual given time and voice in the placement decision

Defining home predominantly in terms of family and social relationships

Developing continuity between home and nursing home via through activities & living arrangements

Elder abuse study

To see how job stress (like unclear roles, too much work, and burnout) predicts how care workers feel about elder abuse.

Findings

• Many workers showed high tolerance for elder abuse

• Burnout was caused by role conflict, role ambiguity, and work overload

• People who were more burnt out were more likely to accept/excuse elder abuse

Culture change

Voices of residents & carers respected

Focused on emotional needs

Enables continued growth

Treat everyone as individuals

Restructuring of staff roles & responsibility

Encourages connections to family & community

Eden alternative

Intended to combat the plagues of ageing (loneliness, helplessness, boredom) often found in nursing homes

Key principles

• Close and continued contact with plants, animals and children. Elders can care and be cared for.

• Daily life that includes variety and spontaneity

• Maximizing decision making by Elders & their families

• Creating an Elder-centered community focused on the well-being of Elders & workers

Findings of effectiveness of the Eden Alternative (may not be generalizable)

Less helpless & boredom

Similar levels of loneliness

Less use of antidepressants, anxiolytics, pressure sores

Lower infection rates & mortality

Lower staff turnover & absenteeism

Less staff-to-staff interaction, greater feelings of responsibility, feeling confined to assignments

Findings of meta-analysis of non-profits nursing homes

More staffing or better quality staffing

Fewer regulatory deficiencies

Patients w fewer pressure sores

Less use of physical restraints

Imp consideration: Effects vary by management styles, motivations, philosophy

For-profit care often means

Lower wages

More part-time jobs

High staff turnover (replacement rates)

Reduced care quality

Traditional medical model

Hierarchical

Focused on physical needs

Routines for residents & front-line workers

Efficient, standardized, cost-driven, rule-compliant focus

Residents often isolated from family & community

Costs of nursing homes

Facility-based long-term care is not covered by the Canada Health Act

In BC, the monthly rates are capped at 80% of the senior’s net income

Varied by province, type of ownership, and model of care

Canadians living in institutions

Increases as age, escalating increases after 80 y/o

Women > men

Only 4% of seniors live in nursing homes in Canada

44% of long-term care homes are private, for-profit

LTC resident needs & health trends

Dementia the most

Bladder incontinience

Heart/circulation diseases, hypertension

Cognitive and physical impairment

Behavioural issues are common (e.g., aggression, disrobing, resistance), stressing staff and family.

Many units are locked for safety.

Nursing home residents mental health and med

44% depress symp

a lot take SSRIs and antipsychotics

Risk is oversedation, falls, movement issues

Non-drug interventions

Music therapy

Animal-assisted therapy

Aromatherapy

Dance therapy

Simulated family presence

Require more staff, training, and commitment to person-centred care

Relocation

Often due to cumulative frailty or sudden health crises.

Systemic issues (e.g., lack of home care, funding, or available facilities) also push people into LTC

Emotional impact: Families may feel grief, guilt, or relief.

Admission process in Canada often involves a single-point-of-entry model that doesn't always honor personal preferences.

Recommendations for smoother transitions

Preparation and education

Clear communication

Personalized evaluations

Team-based support

Use of evidence-based models

Psychological Issues in LTC

One-size-fits-all

Loss of autonomy

Competence-press model

Optimal adaptation (max comfort & max performance potential) occurs when a resident's competence matches environmental demands.

Too little or too much stimulation → negative affect and maladaptive behavior.

Quality of LTC

COVID raised awareness

OVerlooked psyc

Staff shortages and elder abuse

Undertrained staff

Burnout by workers

Suggestions for improving long-term care

Needs of indv should be met max (according to competence-press model)

Non-pharmacological approach can better preserve ADLs, speech, communication, and responsiveness than using meds

Personal support workers should be taught behavioral methods → reduce dependence on meds for dementia patients

Green house model

Offer older ppl indv homes within a small community of 6-10 residence

Open-plan layout of shared spaces, feels like home, medical equipment out of sight

Surprisingly, one study said depressive symptoms might increase w these social interaction

Consistent with culture change movement – promotes person-centered care, makes them feel “at home” despite living institutional settings