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Before proceeding with the proposed consideration, an overview of the challenges facing the older adult, current health system and health care providers is needed to set the scene. Older adults are frequently being blamed as the highest users of health services and thus being the reason for financially burdening the system. Does this mean that older adults should not be allowed the same entitlement to health services when needed? Age-related changes superimposed upon concurrent chronic conditions or diseases and episodic acute illness, requires older adults needing to seek access to health services to attain and often regain the stability of their health and wellness. Approximately 8% of older adults are actually receiving their care in long-term care facilities like nursing homes. The vast majority of the 92% left are independent, active, and living at home. There is within the living at home group, those who are able to remain at home due to supports provided by families, neighbours and home health care providers. There is also another group who are the unknown, who are at home, needing help but not choosing or not able to access the system.
The language currently used by the system and by care providers perpetuates the blaming attitude that reinforces the biases and ageism. Examples of the labeling and devaluing language are bed blockers, frequent flyers, GOMERS (get out of my emergency room). Attitudes voiced as, “They have lived a good life so…,what can you expect?” or “You are old or older…It is to be expected” or the notion that do not resuscitate equates to do not treat even when the condition is reversible.
...the least formally educated of both the informal and formal care providers are the ones doing the lion’s share of the daily care to many complex, frail older adults who are struggling to remain in their homes and not be a burden
There is a wide spectrum of care givers. Informal home care givers are the unpaid family, neighbours, friends who provide the 24/7 supports and care provision that sustains the older adult’s activities of daily living (e.g. nutrition, building maintenance, transportation, banking, personal care) and in many instances quality of life (e.g. love, self-worth, spirituality). The formal caregivers are the providers (e.g. home support workers, care aides, nurses, allied health, physicians) whose care is paid by either the health care system or privately. The health care system appears to believe that as long as they provide the manpower to do the tasks associated with “care”, the system is fulfilling its mandate. In this case, all hands are on board; however, the least formally educated of both the informal and formal care providers are the ones doing the lion’s share of the daily care to many complex, frail older adults who are struggling to remain in their homes and not be a burden.
A great deal of research seems to focus on the development of tools to predict mortality, morbidity, rating or detecting risk or testing approaches that although proven to be efficacious, in day-to-day reality, are not feasible to implement or sustain.
Canada has only about 200 geriatricians and only a handful of physicians enrolled in programs in geriatrics. Advanced practice nurses (both clinical nurse specialists and nurse practitioners) whose specialty is older adults are also few and far between.
The efficacious care of the complex and frail older adults requires specialized knowledge, skills, abilities, attitudes and judgments to provide appropriate quality of life and end-of-life care. The professional human resources to provide this care has been and continues to be identified as a major inadequacy. A contributing factor is the poor understanding that the time and remuneration needed to assess and complete an appropriate care plan for this population cannot be measured by current policies and fee scales. By only looking at quantitative data rather than equitable weighting for qualitative outcomes devalues both practitioners and older adults. In the November 2008, American Geriatric Society journal, several articles re-visited the human resource issue of lack of geriatricians and “specialists” in care of older adults. Canada has only about 200 geriatricians and only a handful of physicians enrolled in programs in geriatrics. Advanced practice nurses (both clinical nurse specialists and nurse practitioners) whose specialty is older adults are also few and far between. Furthermore, allied health professionals such as physiotherapists, occupational therapists and social workers, with a specific educational specialty in geriatrics are also scarce. So, if the solutions and plans continue to focus primarily on producing more specialists to meet the growing demand, then I believe we need to re-think adjacent action plan.
“All hands on board” focuses on increasing the baseline knowledge, skills, abilities and attitudes of all informal and formal care providers who are currently or will be caring for older adults. Having all care providers use a geriatric lens through which they look at and look after older adults wherever they may be, increases the capacity to prevent, detect earlier and timely manage conditions and syndromes that can negatively tip over an older adult into greater dependence and higher needs for care. The geriatric and / or gerontological specialists’ (e.g. geriatricians, geriatric psychiatrists, nurses, allied health) practices will be better utilized and their clinical expertise maximized. All educational programs must have built into their curriculum, care of older adults in order to acquire accreditation. At this time, the Canadian Gerontological Nurses Association and the Canadian Geriatric Society have articulated the competencies required. Furthermore, all health services must demonstrate across the spectrum of care competencies for their service delivery in order to attain Canadian accreditation.
Each province has been working on improving care of older adults. Since I am most familiar with British Columbia, the examples to follow are provided as potential sharing resources to altruistically improve care throughout Canada.
1. Acute Care: There is the recognition that the majority of patients in acute care are older adults; therefore, the need to assure that all staff have the requisite basic knowledge, skills, abilities and attitudes to provide optimizing care and outcomes for this population is essential.
a) From the winter of 2002 until spring of 2008, the BC Ministry of Health, Nursing Directorate, funded the Acute Care Geriatric Nurse Network (acgnn) which was developed and operationalized by the acgnn clinical nurse specialists in acute geriatrics, gerontology, geriatric psychiatry and geriatric rehabilitation. Over 3,000 professional nurses and allied health professionals were educated and mentored in improving care of acutely ill older adults throughout BC.
b) In response to front-line staffs’ requests, the ACGNN Geriatric Giants: Quick Reference was developed and produced as a user-friendly resource. This resource resides on units and on medication carts to help the front-line with their day-to-day recognition and interventions of the geriatric syndromes that frequently are experienced by older adults.
c) From 2005-2008, an additional funded program was offered – Geriatric Emergency Network Initiative (GENI) to improve the care of older adults coming into BC emergency departments (ED).
d) Furthermore, the geriatric emergency nurse clinician (GENC) was introduced to further support the more complex older adults in the ED. These RNs are primarily emergency nurses who have been educated and mentored under GENI.
e) The acgnn.ca website provides another resource to which any staff can refer to in order to increase knowledge and find resources. Coming in the very near future are interactive e-learning modules (approximately 30-45 minutes in length) on 9 commonly seen geriatric giants. Currently on the website under GENI is videotaped presentations with accompanying power points done at the last GENI two-day workshop.
f) Acute Care of Elderly (ACE) units are being gradually introduced in acute care to maximize limited resources to maximize optimal outcomes (including length of stay) for the more complex older adults.
2. Home and Community Health Services: Recognition that the majority of older adults reside at home with greater emphasis to maximize their abilities to remain there.
a) The ACGNN and GENI included professional nurses and allied health professionals in all their educational workshops
b) A great deal of work is being done to assure improved care for both chronic and acute conditions within the home.
c) Palliative and end-of-life care is moving beyond cancer care into all spheres of end stages of any disease/condition.
3. Residential Care Facilities: Recognition that the frailest of the frail with multiple co-morbidities which transition between stability and instability are residing in the 24/7 care facilities. The goal of care strives to maximize quality of life through early recognition when chronic conditions are de-stabilizing or an acute illness is being experienced.
a) The acgnn and GENI included professional nurses and allied health professionals in all their educational workshops
b) Work is continuing to manage acute exacerbations and new illness within the care facilities rather than transferring the older adult to hospital. However, in saying this, there are limits to what very limited professional nurses and allied health can do; therefore, necessitating a transfer to hospital.
c) Many care facilities manage end-of-life and palliative care now.
4. Informal Home Care Givers: The unsung heroes of 24/7 care at home are the informal, unpaid care givers (e.g. spouses, children, neighbours, friends). These care providers are assumed to know how to provide all aspects of care without any formal training. Lack of recognition that they do this at great personal and financial sacrifice continues. However, the need to collectively work together to improve their lot results in the production of non-profit associations (e.g. Alzheimer’s Society, Parkinson’s Society, Heart and Stroke Society, Caregiver’s Associations)
a) The National Seniors’ Council of Canada recognizes the need for federal and provincial support of informal care providers. Through the efforts of one of the members, a focus group was held in the spring in BC and a report written for submission to the Council.
b) A national curriculum for educating informal home care providers was one recommendation in the report.
c) Another recommendation was to include the high school curriculum, how to care for an adult at home.
5. Resources and Other Programs: Recognition that sharing of resources and programs Pan-Canadian and internationally is foundational to moving older adult care direction forward. Some examples are:
a) The University of BC Care of Elders, lead by Dr. Martha Donnelly, is Facilitated by an inter-professional and seniors advisory committee in the development of case-based learning modules on relevant topics related to older adults and their care. Each topic is developed by inter-professional teams with specific expertise the subject. The modules help to build teams, knowledge and problem-solving abilities. Brief descriptions and access to the modules will be up on the acgnn.ca website in the new year.
b) There are a few BC-wide collaboratives which are targeted at specific topics – falls and injury prevention; dementia. These two examples assure that the full spectrum of health services, including informal care providers and prevention are strategically incorporated into the plans.
c) NICE is the virtual counterpart in Canada of NICHE in the USA. Both are aimed at building capacity of geriatric care and knowledge.
In conclusion, “all hands on board” needs to be recognized, formally acknowledged and therefore, always built into all care of older adults. Geriatrics / gerontology, furthermore, needs to be formally promoted as a desired professional pursuit and recompensed appropriately for the complexity of the work.
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