The Place of Assisted Living in BC’s Seniors Care System

The Place of Assisted Living in BC’s Seniors Care System
ASSESSING THE PROMISE, REALITY AND CHALLENGES

By Dr. Karen-Marie Elah Perry June 2020
This report is dedicated to the memory of Frances Belich (1927–2016) and of Carol Pearlstone (1940–2019).
This report is co-published with the Hospital Employees’ Union and the BC Health Coalition

PUBLISHING TEAM
Shannon Daub, Jean Kavanagh, Emira Mears and Terra Poirier Layout: Susan Purtell
Copyedit: Grace Yaginuma
Cover photo: vuqarali / Shutterstock.com

[Excerpts] 2000a3
COVID-19 has shone a light on the state of long-term care for seniors in Canada, including problems resulting from years of underfunding, privatization and precarious working conditions faced by an undervalued, marginalized workforce dominated by racialized and immigrant women. These problems are not isolated to long-term care—rather, they are symptoms of a larger crisis in our fragmented system of home- and community-based health care for seniors.

This qualitative study looks at the state of assisted living prior to the pandemic in terms of the quality and appropriateness of services it provides to seniors, the conditions for both residents and workers, and the legislative and regulatory frameworks that govern assisted living.

The research findings reinforce the urgent need for action driven by the experiences and voices of seniors, their families and the front-line workers who provide care amid frequently impossible circumstances. This study is by no means a comprehensive review of the assisted living sector— but it raises serious concerns that warrant such a review by the BC Seniors Advocate.

The evolution of assisted living in BC
Assisted living was introduced as a substitute for long-term care (nursing homes) with the aim of providing a less institutional, more home-like environment—which is important and highly val- ued by seniors. But for the government of the day, it was also attractive as a cost-saving measure (i.e., by their calculation about as half as expensive to provide as long-term care).

Some assisted living residences are publicly subsidized; others are entirely private pay. In publicly subsidized assisted living, residents pay a monthly charge of 70 per cent of their after-tax income and are deemed eligible to access services by their health authority. In private-pay assisted living, residents pay 100 per cent of the cost directly to the operator, and if the resident requires an additional service, it comes with an additional charge.

Since its introduction in 2002, the assisted living sector has grown to more than 7,600 units provincewide. Troublingly, the majority are owned and operated by for-profit companies, and more than 40 per cent are entirely private pay. The growth of for-pro t and private-pay assisted living, and related a ordability concerns, are analyzed in detail in a companion paper to this study Assisted Living in British Columbia: Trends in Access, A ordability and Ownership.

In 2016, the provincial government initiated legislative changes with the goal of increasing access to assisted living so that more seniors could age in place. This is a positive goal—how- ever, the changes were introduced without a review of the sector to determine if it was, in fact, providing access to quality, affordable services. As a result, many key issues were not examined, including how effective the system was at responding when the physical and/or cognitive health of a resident deteriorated; the implications of having a large portion of the residences that are entirely private-pay; and an assessment of the funding and staffing that would be required to support more seniors to age in place.

Since that time, concerns have been raised by assisted living residents, and their families, and care workers about the living and working conditions in these residences. In response to these concerns, this research project focused on gaining a better understanding of the current state of assisted living in the province.

RELATIONAL CARE
A key ethical value meant to underpin policy related to assisted living is respecting people’s autonomy—that is, respecting their capacity to maintain a level of independence and make meaningful informed choices regarding their care. Currently, BC’s philosophy of care in assisted living emphasizes residents’ “right to choose to live at risk” but without acknowledging the realities surrounding resident “choice.”

Quality of care impacts resulting from undervalued and overworked staff
Research participants in this study had a lot to say about current working conditions for LPNs and care aides. Virtually all care aide and LPN participants in the study emphasized the need for more staff to cope with the increasing complexity of resident care needs. Many reported missing lunch or coffee breaks or paying out-of-pocket for supplies residents could not afford. Care aides also emphasized the wide breadth of their duties, the inadequacy of wages as com- pared to their counterparts in long-term care, heavy workloads and very high injury rates. Many care aides experienced precarious part-time working conditions throughout their career, often working on call.

In subsidized and especially private-pay assisted living, front-line staff reported being unable to do what they ethically know they should as a result of institutional constraints like low sta – ing levels and a lack of resources. These constraints create moral distress for both care aides and LPNs.

[We have] residents coming into care, not accurately or adequately assessed, it happens. And to watch somebody struggle to try to get up because my co-worker is busy, like it just…I feel terrible and it shouldn’t happen, but it does. And ultimately, it’s the residents who suffer for it, you know, physically, [and with their] dignity. (Devorah, care aide)

Care aides emphasized the wide breadth of their duties, the inadequacy of wages as compared to their counterparts in long- term care, heavy workloads and very high injury rates.

To read the recommendations and the full study, please click on: 
The Place of Assisted Living in BC’s Seniors Care System
ASSESSING THE PROMISE, REALITY AND CHALLENGES

UNBC Health Research Institute

The UNBC Health Research Institute (HRI) is designed to enable UNBC’s health researchers to join together for the purpose of furthering health research and innovation. 

The Institute provides a venue for collaboration among this diverse of group of researchers from many disciplines, who undertake various forms of health research, including research on the determinants of health. 

The Institute encompasses researchers working in the areas identified in th​e UNBC Strategic Research Plan (Determinants of Health, Health Services and Policy, Population and Public Health, Indigenous Health, Health and Environment), as well as others who engage in health research at UNBC.

Click on the bold text to access.

Valemount

John Grogan Individual member

grogan_email@yahoo.ca

{Wikipedia} Valemount is a village municipality of 1,018 people in east central British Columbia, Canada, located 320 kilometres (200 mi) from Kamloops, British Columbia. It is situated between the RockyMonashee, and Cariboo Mountains. It is the nearest community to the west of Jasper National Park, and is also the nearest community to Mount Robson Provincial Park, which features Mount Robson, the tallest mountain in the Canadian Rockies. Outdoor recreation is popular in summer and winter—hikingskiingsnowmobiling, cross country skiing, mountain biking and horseback riding are common activities. Valemount is one of 14 designated Resort Municipalities in British Columbia.

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Being a patient partner at Northern Health: John Grogan’s story

A man smiles into the camera.

Daniel Ramcharran  October 16, 2020

Patient partners provide their unique perspective to health organizations and play a crucial role in today’s health care.

We’ve all had experience interacting with the health care system. Patient partners take those experiences and provide suggestions to help improve the care that people receive.

Patient Voices Network ensures the voices of patients are heard

In the North and throughout the province, patient partners are recruited through the Patient Voices Network (PVN). The PVN links partners with a variety of opportunities to work with health agencies and offer the patient perspective. 

John Grogan of Valemount has been a Northern Health patient partner through the PVN since 2014.

“A friend invited me to an orientation meeting and I’ve never looked back,” says John. “I was looking for meaningful volunteer opportunities, and I found it.”

The network posted an opportunity to participate in Northern Health’s Telehealth Strategic Planning Workshop in 2016, which took place over a weekend in Prince George. Telehealth is a service that connects patients with specialists and other medical professionals virtually (e.g., using phone or video), reducing the need for travel. It’s an especially important service for the vast geographic region of Northern BC.

Patient input is valuable and brings thinkers together

John immediately jumped on the opportunity to help. He attended the workshop and a number of presentations addressing all aspects of the potential future of telehealth in the North. They explored how the use of this service impacts not only the health authority, but also the patients themselves.

He enjoyed taking part in the breakout groups, directing questions to presenters and discussing the strengths, weaknesses, opportunities, and threats to using these technologies. John also found ample time to engage face-to-face with some great thinkers.

“I enjoyed it so much, that after arriving home I spent a few hours drafting a post-mortem reflection for the conference organizers,” says John. 
Today, telehealth is playing an essential role in the continued health and safety of health providers and patients alike, reducing disease transmission associated with waiting rooms and travel.

Preparing for a virtual future

Northern Health, the Specialist Services CommitteePhysician Quality Improvement, and the Patient Voices Network have also partnered to offer a workshop for volunteers in ZOOM videoconferencing in anticipation of virtual patient/practitioner visits. John hopes they can expand beyond just PVN volunteers and create a mentorship program to help community members become more familiar with the technology.

In addition, John has had the opportunity to be a part of the following projects:

From: https://stories.northernhealth.ca/stories/being-patient-partner-northern-health-john-grogans-story?keys=grogan

Learn more about how you can become a patient partner today!

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[Excerpts] To read the full article click on the bold text 

Robson Valley opioid clinic needed: local doctors

An opioid agonist treatment clinic could serve the 3,225 people (2016 Census) living in the communities of Dome Creek, Urling, Crescent Spur, Goat River, McBride, Dunster, Tête Jaune Cache, and Valemount within the the 15,220 square km McBride/Valemount Community Health Service Area. Map courtesy Provincial Health Services Authority.

By Fran Yanor / Legislative Reporter
Published on: Novermber 14, 2020

[Excerpts] The Robson Valley has a community need for a dedicated opioid treatment clinic for people dealing with substance use addictions and mental health issues, say two Valemount physicians.

“We have been looking at trying to start up an opioid agonist therapy clinic,” said Dr. Ray Markham, chief of staff at the Valemount Health Centre. “I certainly don’t think a formal clinic is the panacea, but it may offer a couple layers of depth to the way that we can support members of our community.”

“It’s not just about prescribing,” said Markham. “There is a whole bunch of crossover with complex chronic pain and mental health.”

One-stop clinic
“It is super helpful to have a one-stop shop clinic,” said Maureen Davis, executive director of the Canadian Mental Health Association operations in Prince George. “Having a doctor, a nurse practitioner, a social worker, an addiction counselor, having access to all those different kinds of support means you’ve just broadened options for the clients.”

Barriers to access
“If one area of the province has access within minutes, and the other has access in hours, that’s not equitable,” said Ed Staples, president of BC Rural Health Network, which advocates for improved health care in rural communities.

Another obstacle for rural residents is the lack of anonymity.

“Stigma is a real problem,” said Staples.

For the full article, click on: https://www.therockymountaingoat.com/2020/11/robson-valley-opioid-clinic-needed-local-doctors/

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Vancouver


William Day – Individual member
witsend001@gmail.com


William L. (Bill) Day is retired and spends his time in Vancouver.

Bill Day served as Citizenship Court Judge for British Columbia and the Yukon from 1998 to 2009.  He was Adjunct Professor of Higher Education at the University of British Columbia from 1990 to 2001. He  did numerous accreditation studies in the private sector for the Private Post-Secondary Education Commission of BC.

His working career started at Ocean Falls as a young construction millwright.  His work in education was centred in British Columbia, with intermittent work in India and the Philippines under Colombo Plan and CIDA auspices.  He retired from the Presidency of Douglas College, a large urban community college in the eastern suburbs of Vancouver, in 1995.

He was active as a developer, teacher and administrator of volunteer (community based) and school district adult education programs in BC from 1954.  After 1967, he was active in planning and developing community college institutions and programs in western Canada.

He has represented Canada at five OECD consultations on Adult, Recurrent and Distance Education in France, The Netherlands, U.S.A. and Portugal.

Bill received the Order of Canada in 1998 for his work in community, adult and international education, and the development and promotion of the community college concept in Canada.

Bill serves on the (SOHC) Support Our Health Care Board as Vice President and has been very involved with this organization. With research assistance from Nienke Klaver, Bill Day wrote a position paper on National Pharmacare and submitted it to the House Of Commons All-Party Standing Committee on Health on behalf of SOHC. Together with
Ed Staples, President and Nienke Klaver, Secretary, Bill was invited to the Ministry of Health Patients as Partners Initiative – Community Conversations held in  Vancouver (March 4, 2019). Bill has written various Position Papers for SOHC, as well as Letters to the Editor on Pharmacare (https://bcrhn.ca/letters-3/) and Public Healthcare.

Under-regulated, under-researched and largely privatized: Assisted living seniors’ care in BC

Among the key findings:

  • Many seniors have care needs that are not met due to affordability challenges, particularly in private-pay units (where the senior or their family pay the full cost and are charged for each additional service beyond the basic minimum required). For example, LPNs and care aides reported residents using towels as adult diapers or for wound care, skipping meals not included in basic food packages, or wearing dirty clothing because laundry detergent was too expensive or residents could not afford to buy new clothes.
  • A significant number of seniors in assisted living residences do not appear to qualify for assisted living under provincial legislation, which requires that residents are able to direct their own care and independently respond in case of an emergency. LPNs and care aides overwhelmingly reported struggling to meet the needs of residents with moderate to advanced dementia or significant mobility limitations – but who were nevertheless living on their own in both publicly-subsidized and private-pay assisted living.
  • The assisted living model allows residents to make the choice to “live at risk” in order to remain independent, but it can easily become a way for operators to cope with or justify low staffing levels, and too often leaves residents in situations that border on neglect. 
  • In subsidized and especially private-pay assisted living, front-line staff reported being unable to do what they ethically know they should as a result of institutional constraints like low staffing levels, a lack of resources and the philosophy of allowing residents to “live at risk.”
  • Front-line staff participating in this study reported a high rate of ER visits and hospital admissions of residents in assisted living, particularly due to falls.

* We will report back on the government relations and communications regarding the report in the next SC update. So far the report’s launch has been widely successful.

COVID-19 has shone a light on serious problems in our seniors’ care system resulting from years of underfunding, privatization and precarious working conditions. These problems are not isolated to long-term care, however. New research published today looks specifically at the state of assisted living here in BC, and concludes a review by the province’s Seniors Advocate is urgently needed. 

The research study published today by the Canadian Centre for Policy Alternatives, Hospital Employees’ Union and BC Health Coalition is a response to concerns we were hearing from people living and working in assisted living. The study draws on interviews with care aides and licensed practical nurses (LPNs) working in the sector, and a smaller number of seniors in assisted living facilities and family members of residents.

Assisted living was introduced in 2002 as a less institutional environment for seniors with less complex needs than long-term care. It offered the promise of greater independence and being able to live in a more home-like environment—which are important and highly valued by seniors. Assisted living residences provide meals and a variety of mainly non-medical services to seniors living in apartment-like units. In contrast, long-term care operators provide 24-hour personal support and nursing care for residents with severe dementia and/or limited or no mobility.

COVID-19 has shone a light on serious problems in our seniors’ care system resulting from years of underfunding, privatization and precarious working conditions.

Since its introduction in 2002, the assisted living sector has grown to more than 7,600 units provincewide. Troublingly, the majority are owned and operated by for-profit companies, and more than 40 percent are entirely private pay (100 per cent of the monthly fee is paid by the senior or their family with extra charges for any additional service, no matter how small). 

A common theme in the research interviews was the difficulty moderate- and lower-income residents experienced in getting access to the services they needed in private-pay assisted living. While the issue of affordability is much less severe in publicly-subsidized residences, there are still challenges. For example, across both private-pay and subsidized assisted living, LPNs and care aides reported residents using towels as adult diapers or for wound care, skipping meals not included in basic food packages, or wearing dirty clothing because laundry detergent was too expensive or could not afford to buy new clothes.

[One resident living in a private pay facility] fell outside on the patio… She tripped on something and fell and she said there was something in the way… They didn’t even come and see her and ask her what had happened and how she fell and what she fell on. And she has glaucoma so she smashed up her hand and couldn’t put her drops in, so they charged her for putting in the drops. They charge for every little thing. ~Nava, resident

The research also points to a significant number of seniors in assisted living who do not appear to qualify under provincial legislation. That legislation requires that assisted living residents be able to direct their own care and make decisions needed to live safely. LPNs and care aides reported struggling to meet the needs of residents who did not meet these criteria but were nevertheless living on their own in assisted living. This included residents with significant mobility limitations (ex, requiring mobility aides), moderate to advanced dementia, and some who are palliative.

Many of the interviewees and focus group participants commented that assisted living increasingly looks like under-resourced long-term care.

[The] local hospital is very bad at giving them [assisted living residents] a quick assessment and sending them back…and I spend days…on the phone talking to the hospital explaining to them…You can’t send somebody back that’s not walking anymore, that can’t call for that help, that’s not getting out of their room on their own. ~ Saoirose, LPN

When faced with the choice between institutional care or embracing greater health risks in exchange for more independence, many of us would choose to live at risk. But the interviews suggest that living at risk is not always a genuine choice for seniors, nor are the resources needed to support residents, their family members or staff consistently available.

Instead, living at risk is being interpreted to mean non-interference. Assisted living workers I spoke with noted that non-interference easily translates into a way for operators to cope with, or justify, low staffing levels. One LPN manager in a private-pay assisted living residence reported that interpreting living at risk as non-interference all too often leads to situations that border on neglect.

 I found a resident sitting in her chair, frail looking, clothes with holes, not wanting to move, a tray in front of her with untouched food and beverages, I asked this resident to stand, she was unable to pull herself up due to weakness, she had barely eaten in weeks according to a chart in her room, she had tattered soiled underwear with no replacements. I spoke to the General Manager stating we need to get involved in her care as she was deteriorating and not aware of her declining condition, I was told this was not my concern, the resident has the right to live at risk, I called her son who stated she was “fine”, I continued to push anyways to finally have her case worker come in to assess, she was immediately placed in long-term care and passed away within a week. She was suffering and I was helpless to intervene without putting my position at risk with the employer. ~Ava, LPN manager

In subsidized and especially private-pay assisted living, stories like these from front-line staff were common. LPNs and care aides reported being unable to do what they ethically know they should as a result of institutional constraints like low staffing levels and a lack of resources.

 [We have] residents coming into care, not accurately or adequately assessed, it happens. And to watch somebody struggle to try to get up because my co-worker is busy, like it just…I feel terrible and it shouldn’t happen, but it does. And ultimately, it’s the residents who suffer for it, you know, physically, [and with their] dignity. ~Devorah, care aide

As in long-term care, the workforce of care aides and LPNs providing front-line care to seniors is systematically undervalued through low pay and precarious working conditions, and is dominated by racialized and immigrant women.

Care aides interviewed for this study emphasized the wide breadth of their duties, the inadequacy of wages as compared to their counterparts in long-term care, heavy workloads and very high injury rates. Virtually all care aides and LPNs interviewed spoke of the need for more staff to cope with the increasing complexity of resident care needs. Many reported missing lunch or coffee breaks or paying out-of-pocket for supplies residents could not afford.

Virtually all care aides and LPNs interviewed spoke of the need for more staff to cope with the increasing complexity of resident care needs.

Front-line staff also reported a high rate of ER visits and hospital admissions, particularly due to falls. Acute care is the most costly part of the health-care system, and public resources would be better spent on increased staffing levels along with access to training and equipment to support assisted living staff to reduce the risk of falls and staff injury rates, build more support relationships with residents and provide basic health services (e.g., services related to urinary tract infections, complex wound care and palliative care). Improving the working and caring conditions in assisted living could significantly reduce costs in other parts of the health system.

While this research is by no means a comprehensive review of the assisted living sector, it raises serious concerns that warrant such a review by the BC Seniors Advocate, with input from residents, their families and friends, staff and community members along with experts and the province’s health authorities.

In the meantime, the provincial government should immediately enhance enforcement by the assisted living registry, by substantially increasing the number of assisted living investigators, and by developing policies that build on the inspection provisions in the Community Care and Assisted Living Act.

Improving the working and caring conditions in assisted living could significantly reduce costs in other parts of the health system.

Likewise, the province should take immediate steps to address the needs of assisted living workers by reviewing their pay, working conditions, training, and the injury prevention programs provided in the sector.

Assisted Living has become an essential part of the continuum of seniors’ services BC and an attractive alternative for seniors because of its promise to provide care in a “home-like” as opposed to “institutional” setting. And yet, many of the issues uncovered in this study mirror the concerns raised about long-term care since the onset of the pandemic—privatization, low staffing levels, poor quality of care. These concerns require the immediate attention of the Seniors Advocate and provincial government if assisted living is to live up to the promise of providing quality care in a home-like setting.

You can read the full report, The Place of Assisted Living in BC’s Seniors Care System: Assessing the promise, reality and challenges here.

Topics: COVID-19Health carePrivatization, P3s & public servicesSeniors