Health Care Capacity

My wife pointed out to me the other day that in my discussing aspects of the provision of health care, we often use terms that we assume every one understands. Specifically, she pointed to the term “capacity” within the health care system. Today, with the rain confining me to the indoors, I thought some discussion of “capacity” would be appropriate.
Most of us are familiar with capacity in the physical sense. A five gallon pail holds approximately five gallons. In health care, a hospital has perhaps five hundred beds and can therefore accommodate approximately five hundred patients. This physical capacity can be exceeded (unlike a five gallon pail) through changes in the hospitals “functional” capacity. When this happens, it may draw public attention. The most recent examples of this at a simple level, is the “co-ed” rooms and the placement of patients in hospital hallways when there is a bed shortage (which is becoming more and more frequent). The more complex aspect of a hospitals functional capacity has to do with programs such as transitional care, assisted living care, and long term care, in which the Health region has effectively taken the beds of other traditional health care providers and made them an extension of the hospital physical “capacity”. To some extent this was a very necessary change since many people occupying acute care beds were better served in other, less expensive facilities. The concern is primarily the lack of monitoring of outcomes that occurs (or doesn’t) in these “extended” facilities.
The most notable change that has occurred has been increasing the functional capacity of the hospital system by introducing and aggressively promoting home care. This could be considered a policy that extended the walls of the hospitals and its physical capacity to the community, effectively a hospital without walls; the beds of the patients are used as surrogate hospital beds, and the care givers are the loved ones of the patient. Again, to some degree this change in function was needed and welcome, the concern is that there is little or no monitoring of health outcomes in the community, and certainly doesn’t have the attention of the news media compared to the Acute Care Sector (hospitals and emergency departments). As a consequence of these changes in the “functional capacity” within our system, there has been a continual rise in the acuity of illness within the hospital system, the other health care institutions, doctor’s offices, and the community at large. The above changes in both physical and functional capacity within our health care system have been both significant and alarmingly, poorly monitored. Acute care beds dropped from 3.3 beds per thousand population to 1.7 beds per thousand at the present time. It is difficult to quote a figure on long term care beds since now they have different designations at the present, but the bottom line is that there has been little or no change in physical capacity of our long term health care facilities in Calgary over the last 15 years. This means more patient care has been assumed by the patients themselves and their loved ones. Still, the advocates for the present system say more tweaking along similar lines is the answer.
The last and probably the most important and most limiting capacity in our health care system is the “manpower capacity”. I believe salaries comprise approximately 80% of the health care costs in the Calgary Health Region. Although, as mentioned, acuity of illness has increased across the board in our hospitals, health care institutions, and in the community at large, there has not been an increase in staff to patient ratios, and certainly there has not been an increase in training criteria to work in the various institutions. Recent headlines indicate a loss of operating room time this year because of a shortage of surgical nurses. The region states it will be seeking 30,000 more health care workers over the next few years. Calgary Region is apparently short 300 family doctors. Primary Care networks are being heralded as the answer for the shortage of family doctors (a system where your care may be provided by a nurse or someone other than your family doctor). But doesn’t that simply take a nurse or other health professional out of some other part of the health care system?
So the Health Care System can build more hospital beds and operating rooms (increase physical capacity), they can tweak the “functional capacity” a bit more, but the real crunch for the future is the “manpower” (personpower?) capacity. And since this capacity constitutes the majority of the health care costs, don’t tell me that more money won’t help!.

News Media Bias and Health Care

I guess the headlines of the Saturday; May/27 issue of the Calgary Herald answered my queries on my previous blog. The headline read “Fallen soldier’s dad lashes out at Harper” with the subtitle “Grieving father chastises PM for ban on media coverage”. I think the reporting of the death of Captain Goddard in the Calgary Herald can now be classified as a cheap partisan plan to use the death of this brave soldier to bolster the main stream media’s position in their ongoing dispute with Stephen Harper. And quite honestly, if I were part of the Goddard family I would be furious. It would seem to be incomprehensible that the news media would “befriend” the Goddard family and write extensively about this Canadian hero, only to use the matter in selectively taking a pot-shot at Mr. Harper in their final chapter. Little mention was given to the fact that Harper had spoken to the family, and the family had not mentioned that they wished the news media at the ramp ceremony. No mention was made of the fact that Tim Goddard (father) had appreciated the phone call and praised Harper for it. I saw no mention of the fact that the federal government, effective April 1/06 put in place a compensation package of $250,000.oo for the spouse of a deceased soldier. I found that out by reading “letters to the Editor”.
On Question Period today there were four “news types” and the Liberals famous “beer and popcorn” strategist (Scott Reid), all putting forward the viewpoint of the press gallery and one lone Conservative fellow putting forward Harper’s position. Then, Craig Oliver makes a statement to the effect that Harper is being unwise in his approach to the media since the media may hale the new Liberal Leader as the next Messiah in the next election (was that a threat?). The Press claim Mr. Harper is a control freak, but the real issue seems to be that the news media wants control, and are putting themselves forward as the people’s representatives; duly authorized to dictate to the government on how information is to be released to the press. I recall the Election in January electing Mr. Harper; when was the election that elected Craig Oliver and the Ottawa News Bureau?
In the interview with Manitoba’s Premier Gary Doer, Mr. Doer points out that Mr. Klein gave a very insightful, intelligent, and scientifically based address a year or so ago at a high level ministers conference discussing B.S.E., and the news headline reported the “Shoot and Shovel” quotation with regards to the BSE problem.
So what if there really is a bias on the part of the Main Stream News Media regarding conservative positions. How does that affect our health care system? Probably, we will continue to be mired in the status quo for years to come. Over the last while I have read news articles stating “Canadians don’t see wait times improving”, surgery patients waiting longer, operating room nurse shortages, and an article on a family doctor who stated that his expenses were significantly eroding his take home income year after year. The Calgary Health Region states that it will need an additional 30,000 health care workers over the next few years. The most recent editorial response to this dilemma has been in the Thursday, May 24, Herald editorial page: “More money not a cure” and the subtitle “keeping doctors in Alberta hinges on job satisfaction”. In the editorial, the writer shows a remarkable lack of understanding as to the activities and income of a family doctor, but my real objection to the article is that the job satisfaction of family doctors in the work place will necessarily revolve around the issues of access to both technical and human resources (C.T. scans, MRIs, specialists) and reducing our stress in the work place. All of these things are directly related to funding or lack thereof. David Finch, in the May issue of Alberaviews, also states “Money alone can’t solve the health care crises” but then goes on to say in his article “The waiting times for hip and knee surgeries fall drastically after a major philanthropic contribution”. Alberta’s pilot project on shortening waiting times on hip and knee replacements has enjoyed some success with the help of tens of millions of additional funding dollars. So why does the news media continue with the mantra “more money won’t help”? Is it because more money in health care means less money in other social programs, education, child care, infrastructure, etc, and the news medias political views do not support outside avenues of obtaining health care to defray expenses from the public system? Mr. David Finch provides us with the answer: “We need more wisdom in the system”. In particular, by the example he gives, he presumes much money can be saved by more carefully considering who to spend our tax dollars on in our health care system. Now why isn’t that idea considered SCAREY by the national news media?

Our Pride or Our Shame, Your Call

I may have to stop reading the first few pages of the Calgary Herald or watching news reports. For the last week to ten days the feature story has been the death of Captain Nichola Goddard. Indeed, her death is and has been a tragedy and my sympathies go out to all who knew her and loved her; but surely, in battle, one should expect casualties. Are expected deaths more noteworthy than unexpected deaths? If that be the case, the deaths of the many Canadians waiting on our many and long “risk lists” should make front page news daily. Is anyone even keeping score?
It would be interesting, for instance, to know how many people in Canada who are waiting for coronary angioplasties, die of a heart attack before the procedure is done. Even if they do not die, but suffer a heart attack, there will be heart muscle damage and life expectation will be shortened. I’m sure there is ample statistical evidence; otherwise there would be no need for anyone to have the procedure done. The physicians involved in categorizing patients into emergent, urgent, semi-urgent, and elective, are doing their best with the information available to them, to minimize the risk of waiting, but the correct word is “minimize”, not eliminate since their decision is a medical “opinion”. And in my experience, the intervention cardiologists generally conclude that they would feel more comfortable within a shorter time frame. In other words they recognize the “risk” involved in the waiting time interval.
Hospitals and health regions, to my knowledge, have always had wait time definitions (emergent---within 24 hours, very urgent----within three days, urgent----within ten days, semi-urgent----within three weeks, and elective----within six weeks). These time intervals may have varied slightly from hospital to hospital or region to region, but generally were based on the opinions of the medical staff with the “know how” and some agreement from the administration. There is also general agreement of this group of “experts” that the wait times suggested are generally not adhered to; not through negligence or lack of compassion on the part of the care givers, but through lack of capability and capacity within the system (e.g. lack of operating room time, hospital beds, and skilled staff/nurses).
So why is it that we have read volumes in the newspapers about Captain Goddard untimely demise and nothing of other Canadians untimely demise? Is it because she was fighting for a just cause and Canada could take pride in her ultimate sacrifice; perhaps it is because she is the first Canadian woman to die in a military struggle (I must admit, I do not know if that last statement is accurate)? Today, Nichola’s father said that he wished to underscore the fact that Nichola was more than a soldier; she was a wife, a daughter, a loving and real human being.
Is the main stream news media trying to turn public opinion against Canadian involvement in Afghanistan, or is it an attempt to generate some Canadian pride.
But surely the lives of the people who are dying waiting for their angioplasties are equally significant. They are someone’s wife, mother, father, husband, grandmother, brother, etc. Why do we not have front page headlines on these people? Is it perhaps that the news media doesn’t know of these sacrifices? If so, what happened to investigative journalism? Or would we find that the Health Care System that we now hail as our pride would actually be the subject of our greatest shame?

Sheila Found Money For Health Care!

So according to the federal auditor, Sheila Fraser, the long gun registry has set Canadian tax payers back approximately one billion dollars and the on going costs of maintaining it would be approximately eighty two million dollars annually. I heard that of the last 540 homicides in Canada, two were by long guns. Apparently no one at this time is able to point out specific instances were the registry has actually saved a life and Sheila Fraser notes that, even with the additional moneys spent on the “revised” computer program, there are significant problems that preclude reliability on the information that may be obtained from the registry. It would seem that this was an “innovative” idea on the part of someone to deal with homicides in Canada. If it really is the “thought that counts”, the formulators and the instigators of this brain fart could pat themselves on the back; unfortunately, its lives that count.
On many of my previous blogs I have talked about cost effectiveness in medicine, allocation of government revenue, relative, rather than absolute scarcity of resources, and competing interests for government tax dollars, etc. As a physician, I can assure you, and I can outline programs that would save hundreds of lives with the money squandered on the long gun registry. My wife gets notification when it is time for mammograms and pap smears as do most other women in the appropriate age group in the Calgary Region (a good pro-active step in finding cancer early). I have suggested a similar program for regular screening for high blood pressure and diabetes since two thirds of people with high blood pressure either don’t know they have hypertension or are inadequately controlled. Two thirds of people with cholesterol levels that are too high would also benefit from screening and treatment. This idea was rejected by Iris Evans, as I reported previously on my blog. Would such a screening “reminder system” cost over a billion dollars? Possibly; but I can guarantee that it would save thousands of people from strokes, heart attacks, and death.
A few days ago I attended a meeting of the Calgary Health Region and department of Family Medicine, which was to inform family physicians on the Regional state of preparedness of the Calgary Health Region in the event of an influenza pandemic. In the event of a pandemic the Region intends to decrease their active treatment beds for medicine and surgery from the present 2200 beds to 700 beds, setting aside 1100 beds for the treatment of influenza patients. They estimate that because of illness within the care giver population, 400 acute treatment beds will need to be taken out of the system. It seems obvious to me that under this scenario family physicians will be swamped looking after the people in the community that usually are being serviced in those hospital beds but are now either not being used because of staff shortages (sick with flu) or are being used for the care of people critically ill with influenza and its complications. Now comes the “zinger”. Most of the session pertained to the roll of family physicians in the event of a flu pandemic. Suggestions were made on how to clean our offices to decrease spread of the virus, triage our patients to come in at the end of the day if one suspects the flu, show patients directly into an examining room if flu is suspected, etc. The suggestion was made that we have “an alternate relief office nurse” in the event our regular office nurse gets ill (don’t they know that many years family doctors and their nurses don’t get holidays because of a shortage of “relief” professionals). It was acknowledged that antivirals (such as tamiflu) may not be effective and that it would take three to four months to “develop” a vaccine. The plan was to NOT have training sessions and people in place beforehand because the situation may vary somewhat from year to year and the information provided would then have to be modified. In short, I saw little evidence of a concrete workable “plan”(Could lack of funds be a factor?).
Here are some things that I think should be considered if we are to even begin to cope with an influenza pandemic:
1) In the event of downsizing hospital bed use, as suggested to accommodate influenza patients, family physicians will be so busy looking after the “usual illnesses”, we will have no time for influenza patients. Slowing down the office practice with special procedures to deal with influenza patients will simply mean nobody will be properly cared for. Furthermore, patients often simply walk into a medical office without an opportunity to triage them (we should note that at present Calgary is 200 to 300 family physicians short).
2) Influenza centers should be set up in vacant schools or auditoriums to deal with influenza patients and as many patients as possible seen in these centers. These centers would be the primary recipients of medications and supplies needed to treat influenza. A determination should be made as to how many, and where these centers may be located, and a tentative skeleton staff determined for each one.
3) Education of the public should start now. This would not only pertain to influenza per se (such as the use of an antiviral within 48 hours of onset of illness) but would include information about influenza centers, services available there, and their use instead of doctor’s offices and the emergency departments.
4) A core of professionals and lay people should be on “retainer” similar to a military “reserve force” that are kept current on the latest influenza information and the role they would play in an influenza center. This group would be called upon early, both as educators and participants in the first “wave” of a pandemic.
5) Schematics of an influenza center should be drawn up from both a physical and functional perspective.
6) Specifics should be addressed as to the priorization of both antivirals and vaccines.
7) Definitive packages need to be negotiated with governments that would compensate the family of care givers who die as a consequence of working in an influenza center similar to compensation for the families of military men lost in war. We were informed that at present “the powers that be” are negotiating a type of “no lost income” agreement with the A.M.A. and the doctors. I see this as minor compared to the impact of a family loosing one or possibly both parents that are care givers.
Well, the above is a start, and it will cost money; but unlike the long gun registry, I’m sure those hundreds of millions of dollars will save thousands of lives. And if we get a pandemic, you can be sure that some of those lives will be very close to home.

Whose Life Is Worth Saving?

Here is a new twist on the cost effectiveness scenario. Experts looking at the issue of a coming pandemic influenza have recommended that the ideal group to immunize and the group that should be immunized first in the event of a pandemic is the 18 to 30 year olds. Their rational is the following.
1) Society has invested considerable cost in getting them to the age of being productive.
2) They will be entering the work force and therefore will be the next-in-line tax payers for the longest expected period of time.
3) They should be the healthiest and therefore most likely to survive the influenza with the help of the immunization (notice, I did not say “benefit the most”)
4) They can work as the caregivers.
5) Saving lives in this group will prevent orphans that would need to be raised by the state.
Traditionally, the aged and the chronically ill are given preferential immunization. They argue that this is inappropriate and this group:
1) Are past their peak in productivity anyway.
2) Are less likely to survive even with immunization,
3) Will be less likely to be care givers to the influenza patients
4) Have contributed most of their life’s contribution already to society (taxes).
5) Have the least “life years” remaining.
Although the pediatric group will have many years to benefit, there will be additional costs to bring them to the age of “contribution”. All this deliberating was of course brought about by the following facts:
1) There will be a shortage of vaccine,
2) There will be delays in immunizing the populations of the world simply because of the enormity of the task, and the limitations in numbers of people available to do the immunization.
The obvious conclusion (in their minds), is there must be priorization to the immunization process to be cost effective and be for the “good of society as a whole”. So much for the idea that as a free society and in our health care system, we don’t make judgments as to relative values of human lives.

Nursing Homes, Part Two

I now continue with my suggestions, wishes, and deliberations on things that I feel would constitute the ideal (and perhaps doable) nursing home facility,
1)Medications and Pharmaceuticals: Small variances in medications can have significant effects in those who are least stable, from a medical perspective. At present, most nursing homes will stock one or two drugs from a class of drugs, and the patient gets the particular drugs that are stocked. In many cases there is no harm in this, however, broad allowances must be made for individual variations, and if a family wishes to supplement the “pharmaceutical” requirements of a patient on the advice of the attending physician, there should not be negative attitudes on the part of the nursing home. More medications could be used for dementias, osteoporosis, and other chronic diseases but there is a lack of consistency in application of many proven modalities and medications, and the cost of some medications is prohibitive. On the other hand, I truly believe that there are many medications that are continued inappropriately in circumstances where a patient’s status has changed. Our nursing homes have moved significantly to improving this area of care by having multidisciplinary patient care conferences on a regular basis. Unfortunately, they occur too infrequently and not soon enough after the initial admission of the patient.
So our ideal nursing home will have a multidisciplinary meeting within a week of the patient’s admission to a long term care facility (this would include the family of the patient, the patient, the patient’s family doctor, the physician that will be assuming care, and other professionals that will be involved in the care of the patient). Further, such meetings would occur every three months or at other times as requested by the family.
2) The facility: (a) As already mentioned, many newer facilities have been significantly improved by having more private rooms. This would seem to have been a “good thing, but in some ways, for some patients, this was not a benefit. Having an appropriate room mate can be ideal for an elderly person who was married for fifty years and is accustomed to a “room mate”. The private room can be a place for regression and isolation, and as previously mentioned, requires more “travel time” on the part of the care givers to attend their patients. Having a blend of larger “double occupancy rooms” with some private rooms would likely be ideal. In addition, the facility should be able to accommodate married couples, even though they may be at different “care levels”. All too often couples who have been married for sixty years are separated during placement. To me, this represents abandonment akin to death, since the partner not institutionalized may not be able to travel or visit. On occasion both may be institutionalized, but to different facilities.(b) The facility must include the necessary medical tools to look after a group of patients that are ever increasing in medical complexity and acuity. Various areas of our long term care facilities are designated “transitional care”, or “palliative care”, and in general there is an ever greater need to be able to medically assess, on short notice, this group of patients. Having the ability to monitor oxygen saturation, do blood work, and basic X-ray imaging, should be on site. Why are diagnostic facilities located in shopping centers? Community patients could access these modalities if they were part of a geriatric facility, and the in-patients would have access and availability. As it is now, if I wish my nursing home patient to have an X-ray, someone has to cart them off to a shopping center or wait for hours in an emergency department. The integration of community patients in the form of a “day hospital” at such a long term care facility would also be a plus. (c) The location of the facility is extremely important. In the last ten years, elder foster homes have been sponsored and promoted by the government in the large cities, while large nursing home facilities were being built in the country. The reverse should happen. In the city, a large nursing home should be located ideally in an older community. Fewer people would be dislocated, especially if they were given preference of placement. This would enable visitation from friends and a draw of healthy “similar aged” volunteers. Out patient programs in such a location would be advantageous to the community at large. In the rural setting, elder foster placement or small scale institutions are ideal. Abuse would be rare since in small towns everyone seems to know what everyone else is doing, and friends and relatives would have easy access. Building large nursing homes in the country often means that the patient’s elderly friends have to travel 40 or 50 miles to visit, and many in this age bracket don’t drive. The result has been isolationism to the extreme.
So, to clarify this issue, our ideal facility in the city would be large, located in an older part of town, have an out patient treatment aspect, have a mix of private and semi-private rooms, and have basic laboratory and X-ray facilities that could be used by the community as a whole. In the smaller rural communities, a more ideal setting would be elder foster care or smaller group homes, where there can be more involvement of friends and family, with the consequent capability of transporting the patients for services that may be required.
Before closing, I would like to pay tribute to the many wonderful hard working and caring care-givers that work in our long term health care settings. In my experience, this group is among the finest in our health care system. They are, however, stretched far too thin. During one of the regular November flu outbreaks, one of my nursing home patients phoned me from the nursing home and said she thought she had pneumonia, and that the nurses wouldn’t phone me. After the office I dropped by the nursing home and confirmed the patient had pneumonia and was admitted to hospital. Asking the charge nurse about this incident she said: “Doctor, we haven’t time to properly assess each patient during flu periods, much less phone the physician for each patient that has the flu. One third of our residents are sick on top of their usual problems, one third of our staff our sick and we don’t have the relief staff to replace them. With each flu season we are in a care crisis here”.
This has been a basic sketch of our institutional “elder care”, and of some aspects of what I would call an ideal “elder care facility. In some ways, it would resemble the old community hospital with the care being less “high tech” and less acute than our present day city hospitals, with a stronger emphasis on comfort, caring, and support, but with strong medical backing. There is no need for large palatial, hotel-like accommodation. Keeping simple and effective is the key. But don’t hold your breath waiting for things to go in these directions. As one gerontologist said: “But our old people will live longer, and how is that going to be cost effective”?

The Sunset of Your Life.

In the spirit of being constructive and not just criticizing the present day care of our elderly, I thought I would consider some aspects of long term institutional care for the elderly that could be considered ideal and doable. To do this we will have to look at the needs of the elderly based on their known common problems, and modalities and approaches that have been shown to be effective.
1) Exercise: This is probably one of the greatest short-comings in our present day long term care institutions. I recall a study done that took elderly nursing home residents that were confined to wheel chairs, and had them do five minutes of upper body exercises three times a day. The particular study was designed to look at the effect of exercise on bowel function, but at the end of two years the group on this simple exercise protocol not only did better in respect to bowel function, but also appetite, sleeping, behavior and other parameters. This protocol was not implemented in the nursing home as an ongoing practice because of staff shortages. Many nursing homes have access to a physiotherapist, and this is useful, but for the most part the physiotherapist is asked to address specific issues. Recreational therapy is also often available, but many of our seniors are not accustomed to the “ideology” of recreational therapy. Walking is an almost universal form of exercise for our seniors. Unfortunately with our long icy seasons in Canada, outside walking is prohibitive and dangerous many months of the year. One of my 90+ year old nursing home residences walked outside in the parking lot even with snow blowing and freezing temperatures, and in spite of the fact that she was legally blind. I admonished the staff for not accompanying her and they informed me that they simply did not have the staff for one to one activities such as outside walking. Needless to say, this particular nursing home had nothing but hallways (lined with wheel chair patients) to accommodate her walking indoors. For those seniors that have problems precluding walking, hydrotherapy is very effective. Walking in water holding onto rails takes weight off of the weight bearing joints such as knees, feet and hips, and the water offers resistance that increases the work load. Unfortunately, this also requires personnel and supervision.
In summary, an ideal facility should have an area that is reasonably pleasant and safe for patients to walk, a recreational program, a physiotherapist, a hydrotherapy pool, a walking pool, and sufficient staff to meet safety criteria (the staff need to be capable but not necessarily highly trained). I find it interesting that the newer hospitals (where early discharge is the imperative) have open spaces for patients to walk, but in our nursing homes where patients will spend the rest of their lives, our elderly have to walk in crowded wheel chair areas or parking lots.
2) Socialization: The mind is similar to the body; if you don’t use it, you lose it. Although group socialization for some patients is helpful, many patients, because of problems such as decreased vision, hearing, or social skills, find group socialization stressful and are unable to benefit from groups. However, one to one socialization is a benefit to all. This is an area where staff can be extremely helpful. Interaction between the patients and all members of the staff is extremely important. The people cleaning, preparing meals, nurses, etc, should always take an interactive role with the residents. Asking about relatives, the day of the week, the weather, any kind of interaction, has been shown to help delay dementias, prevent aberrant behavior, prevent depression, and be therapeutic. Since hearing is frequently a problem with the elderly, speaking slowly and clearly, face to face is best. Because once again this is an area where staff shortages play a role, an active volunteer program would be great. Ideally, other healthy aging people are best, although I have seen elderly patients respond dramatically to High School and University students as well. One elderly lady who was actively visited over a long period of time by two young college students, decided to help them financially complete their studies. Perhaps programs could be set up in schools where as part of a health-science program, students could spend a period of time with institutionalized seniors and write a report on their experience for study credits. So let’s add a very active recruiting program, and community integration programs, to our ideal nursing home. Unfortunately, at present, most interaction occurs in a group setting (lack of staff and cost effectiveness).
3) Professional Staff: There has been a continual downgrading of professional staff in our long term care facilities. Not only have there been inadequate staff-to-patient ratios, but there has been an ongoing trend to replace R.N.s with L.P.N.s. The chronically ill elderly are the most vulnerable in our society. They are often on many medications and need close and careful monitoring. Yet, during some shifts in large nursing homes, only one R.N. may be on duty and be responsible for the L.P.N.s, any physician communication or orders, critical nursing assessments, etc. A clear understanding during conversations when a physician is receiving information and giving orders to deal with this fragile group of patients is vital, yet it is not unusual for the nurse supervisor and other care givers to have English as a second (and weak) language.
So we will add, not only increasing numbers of care givers to our ideal facility, but increasing numbers of R.N.s with a special interest and training in geriatrics.
I will close today’s blog for now and complete my “ideal nursing home” wish tomorrow.

We Need Courage To Grow Old

You’ve got to be brave to get old! I bet I’ve been told that hundreds of times by my geriatric patients over the years. A close second in advice given to me would be: “Getting old isn’t for cowards” and a third choice would be “If these are the golden years, they can have them”! One eighty five year old fellow would routinely start off every visit with: “Doc, I’ve got a bit of advice for you, don’t get old”.
So getting old isn’t all that delightful, it would seem, and the problems associated with aging certainly aren’t new. But for some reason there seems to be a lot more media attention to the plight of our elderly citizens, and groups speaking out on their behalf. There seems to be continual discontent with various facilities to house our seniors, the lack of entertainment for them in these facilities, and the paucity of staff to care for them. Many of these complaints are justified, but rarely does the person or group complaining come up with suggestions, other than their “wants” for their loved one. Obviously, there is a general lack of understanding of what is happening in our health care system, and how it impacts on the care given to our elderly in our nursing homes.
I think that thirty or forty years ago one could honestly say that nursing homes were truly a “warehousing of the aged”. Many of my patients in those days regarded nursing homes as a place to go to die. As geriatrics became a recognized field of medicine, and as we found more and more evidence that this group of patients responded extremely well to various medical and social interventions, pressure was brought to bear on enhanced medical approaches to our elderly and to our long term care facilities. As this was acted upon, some studies showed that spending on seniors increased by as much as 20% in some years. To curtail costs in Alberta, the Alberta government put a moratorium on the building of new long term care facilities. From a medical perspective, the previously used “you’re too old for this procedure, or this drug doesn’t work in this age group” simply was found to be wrong. Accordingly, renal dialysis and other technological interventions were offered to an ever aging group of patients. Statins, a medication group for lowering cholesterol, initially were not used in people over 65 years of age because it was suggested that this group already had established cardiovascular disease. Interestingly, more and more recent evidence suggests that this group benefits as much or more than the younger age group since the elderly are the group MOST AT RISK. It would seem that as time goes by, the more we learn about the elderly and their treatment, the more effectively we can treat them; they live longer and have a better quality life.
From a payers perspective (the government), it is not money well spent. Because these elderly people are at the sunset of their lives, interventions do not provide a sustainability of cost savings. Interventions in the young can provide good outcomes and low health care costs for fifty or sixty years. In the elderly, costly interventions will provide good outcomes for relatively short periods of time, but ongoing costs, for the remainder of their lives. This is the conundrum the taxpayers of Canada and its administrators (governments) face. The Canada Health Act was brought in to protect the poor, the chronically ill, and the frail elderly, but from a cost perspective, this group is the very group that invested money creates the worst long term results from a cost perspective, but very good short term outcomes from a medical perspective.
The irony is the objectors to private insurers and a private parallel health care system say the insurers won’t cover this group with high health care needs. Of course not! Insurance is for unforeseen events, not ongoing care of the poor, chronically ill, and frail elderly. Medicare was brought in specifically for that group.
Lynda Jonson, a strong advocate for improved care for our seniors, is concerned about the lack of adequate staffing in our long term care facilities. Previously, advocacy groups insisted on more private facilities for our institutionalized seniors. With the new larger private rooms, the nursing staff has twice the area to cover to see the same number of patients as when there were two patients in one room. Consequently, the need for more staff has become even more of a problem in the newer facilities. Adding staff for recreational therapy, physiotherapy, etc, has improved staff ratios without addressing day to day bsic care needs. I recall one dear elderly soul who, because of physical incapacity (but still having perfect mental capacity) was unable to address her toileting without help. “Do you know how humiliating it is to ring for assistance and finally after an hour pee the bed and lie in it for a further half hour” she would ask me? The nurses were unhappy with me, but I wrote an order for this lady to be bed-panned every three hours whether she rang for a nurse or not.
In an effort to contain cost, governments and regional health authorities have set up an elaborate system of classifying patients, and then designating them to an “appropriate” care facility. Lynda Johnson mentions reclassifying an area of an existing facility to the designation of “assisted living” instead of “continuous care” facility, and how the change in designation enables a lower staff ratio. It also changes the amount of government money available to the facility.
The truth is, a continuous downloading and reclassification has been going on for many years to enable cost savings. Certain criteria need to be met to access our hospitals because of limited space, transitional care is a step down from hospital care, home care is using the patient’s “home” bed as a hospital bed, and loved ones as care givers, assisted living is using more of the patients money to provide their needs, and continuous care facilities now are filled with people who once were more appropriately housed in a community hospital. The thrust is to steadily decrease spending on the frail elderly and chronically ill and downloading the responsibility on the patient and their loved ones-----the very thing Medicare was meant to prevent. So cheers to Lynda Jonson and other senior’s advocates, we need you. As the baby boomer generation has its impact something will have to give. Hopefully it won’t be the casting aside of your mother, father, grandma or grandpa, in an age that is prone to “disposables”.