Seniors’ residential care system puts focus on social interaction
The crossword on Dennise Keefe’s door is a nine-word autobiography: His friend Chris saved his life, he was a short-order cook, he loves rock ’n’ roll music, he’s a whiz at cards, and he makes coffee every morning at his long-term residential-care facility.
“It makes me feel really good,” said Keefe, proudly pointing out the ZZ Top posters and high-scoring cribbage hand also taped to his blue door.
In Vancouver’s Youville seniors home, staff recently helped residents decorate their doors as part of a “megamorphosis” movement by Providence Health Care to make these facilities look more like a home.
“If you enter into many facilities for residential care, or care homes, these days you might think you are in a hospital, and that is not really a place you want to spend the end of your life,” said Dr. Ken Tekano, Providence’s head of residence care.
“So within the constraints of the physical space, we are trying to shift the model from a medical model to a social model. And that is the way of the future, from our perspective.”
Recent data collected by the B.C. seniors advocate, Isobel Mackenzie, indicates socialization must be improved in most of B.C.’s 293 residential care homes.
Even though these retirees live with many people, nearly half say they feel isolated and have little social engagement when it comes to interacting with other residents and taking part in activities.
Indeed this was an area where Youville — a specialized home catering to residents with challenging behaviours, which also has a mental health unit for older adults — needed improvement when Mackenzie gathered her statistics in 2016-17. Nearly 75 per cent of residents reported feeling isolated then.
Today in Youville, quilts, fancy hats and painted flowers adorn the walls that lead to the personalized doors, which provide a small introduction to the person who lives inside.
Staff painted “A good looking piano man lives here” on the front of Roy Vowels’ green door, prompting a recent visitor to ask him about music. While he shyly talked about his mother teaching him to play and about being in a band, it is clear he is very modest about his musical accomplishments — and his looks.
This inexpensive program has been done at two Providence residential homes, and the intent is to expand it to the rest, Tekano said.
Loneliness can be as bad for your health as smoking 15 cigarettes a day, some studies have shown, and is a topic families may want to raise searching for a home for a loved one.
“Ask what kinds of recreational programs the home has. How many staff ? How many active volunteers a facility has. What does the calendar of events look like? Are there things happening here that are of interest to my relative?” are questions suggested by Jennifer Baumbusch, a UBC assistant professor in nursing and an expert in long-term residential care.
“Also look at the physical environment, talk to residents as you walk through to see if they are engaged and happy and doing things they like.”
Earlier this year, Mackenzie released a report based on information she gathered for all B.C. care facilities, which have 27,142 publicly subsidized beds, and offers an online tool (at seniorsadvocatebc. ca/quickfacts) to look up stats on each home.
Postmedia analyzed the raw data collected by Mackenzie, and below looks at several other key areas of concern.
CARE HOURS
While Mackenzie and others have long lobbied for an average of 3.36 direct hours of care every day for each senior in a residential home, her figures show the average in 2016-17 was 3.14 hours, a slight improvement over the previous year.
While all facilities receive funding from health authorities, twothirds are run by private companies and only four per cent of those get enough money to provide the full 3.36 hours of care. The rest of the homes are run by the health authorities and one-third of those are able to reach that goal. Indeed, more than 60 facilities across B.C. are cutting their residents short by a half-hour or more every day — that’s 30 minutes less help for bathing, dressing or just having a conversation.
Baumbusch said it’s unfortunate this disparity exists in a system in which people waiting for residential care must go to the first facility with an available bed, and then remain on waiting lists for other places they may prefer.
“I don’t think it’s fair to people moving into a first-available-bed system: ‘You are going to go wherever we put you, but we can’t promise you a staffing level,’” she said.
“I think with so many aspects of seniors care, the planning for this large cohort of older adults hasn’t really happened. It has never been prioritized to the point where they have the services in place.”
The year-old NDP government has made the problem priority and has budgeted $240 million to hire 1,500 more care aides and nurses by the end of 2021 to get those care hours up to an average of 3.36 at every home, Health Minister Adrian Dix said. This, of course, will not address the increasing demand for more residential care, but will address the needs of people already in care.
Daniel Fontaine, head of the B.C. Care Providers Association, said some homes have started to receive this funding, in particular the privately run facilities with the lowest hours. But both Fontaine and Dix agree money isn’t the biggest challenge: It’s where to find all the care aides they need to hire, especially in rural communities and the north, where it has traditionally been harder to recruit staff.
“This could take years to implement. And we are beyond just talking about the aging population, we are in the middle of it,” said Fontaine, whose organization represents privately run care homes.
Last fall, he presented the government with a proposal on how to train more care aides, which involved unions, colleges and highschool job-training programs. Fontaine hopes to hear some commitment soon from the ministry on this plan.
FALLS WITH INJURIES AND RESTRAINT USE
Holy Family Residence in South Vancouver has started a program believed to be the first of its kind in Canada: Community volunteers interact with seniors in the home daily between 4 and 7 p.m., a time period in which residents were having falls most often.
Twenty-one “fallunteers,” including Preet Mangat, help residents reach items so they don’t lose their balance or play board games with them so they are less restless in the evenings.
“We are trying to prevent falls with having an extra pair of hands around,” said Mangat, 19, a UBC biochemistry student.
Falls with injuries is one of the categories analyzed by Mackenzie. On average, for every 100 beds in a facility, there were 10 times when someone fell and got hurt in 201617. That number was higher than 20 falls per 100 beds in 25 of the homes.
Holy Family’s rate was relatively low, at 3.5 injuries from falls for every 100 beds, but the facility hopes to get it even lower. The fallunteer program began as a research project in 2016, and expanded in September to three volunteers interacting with more than 100 residents each evening.
There is equipment that facilities can use to reduce injuries from falls, such as specialized lighting at night, beds that can be lowered to the ground, and shorts with padding around the hips, said Baumbusch. She encourages families to ask facilities about these options, and if there is any cost to the resident.
Mackenzie’s report found physical restraints — which she defines as something that holds “limb and trunk” and the use of reclining chairs that prohibit getting up — are also sometimes used to reduce falls. An average of eight per cent of seniors in residential care had daily physical restraints between October 2016 and September 2017, down from nine per cent the year before.
Tekano, who is also regional medical director of residential care for the Vancouver Coastal region, strongly objected to the idea that nursing home residents are being bound to beds or chairs today. Instead, the type of “restraint” that might be used includes a lap tray, wheelchair seatbelt, bed rail, or a wheelchair that tips backwards, he said.
He said residential care is moving toward allowing people as much freedom to move as possible, but noted some families are worried about their loved ones being at risk of falling.
“It is truly bordering on cruel to prevent someone from mobilizing who can (walk),” he said.
Baumbusch said restraints such as table trays and seatbelts can be over-used when staffing is low in a home.
“I don’t think any of us can imagine sitting in the same for spot hours on end. We always have to put ourselves in the position and ask: Would this be acceptable to me?” she said, adding families should tour facilities they are interested in. “I would look to see if residents are up and walking and mobilizing on their own, or is everyone in a wheelchair with their feet up on foot pedals?”
ANTIPSYCHOTICS
Another area of concern for Mackenzie is the use of antipsychotic
medications in residents who don’t have a diagnosis of psychosis. She found this was happening with a whopping 25 per cent of residents in 2016-17, down from 27 per cent the year before.
“It’s a desperate effort to help the care staff deal with ‘disinhibited’ behaviours from folks suffering from dementia,” Tekano said when asked about the off-label use of these medications.
“Typically these medicines are started in response to some sort of crisis situation.”
Seniors might, for example, act out because they’re frustrated by an inability to communicate, he said, so the medication can be used to suppress that behaviour — perhaps because staff don’t have the time to understand the behaviour.
In 10 of the province’s residential care homes, 50 per cent or more of the residents are being given antipsychotics without a proper diagnosis. Two of the worst offenders are in the Vancouver Coastal region that Tekano oversees, but he said the statistics are skewed in those facilities because they are referral centres for people with challenging behaviours and psychiatric conditions.
Fontaine, of the B.C. Care Providers Association, said one of the biggest challenges for the homes is that seniors coming out of acute care are often “on a basket of drugs,” which can be hard to wean off.
Both he and Tekano believe increasing care hours and education will help to continue the downward trend Mackenzie found in reliance on these meds.
“We are making progress. We are not where we want to be, definitely, but I like where the numbers are going,” Fontaine said.