Advancing Continuing Care A blueprint to support system change

Transcription

1 Executive Summary Advancing Continuing Care A blueprint to support system change Most people with chronic illness or disabilities want to continue to live in their own homes for as long as possible. Since 2006, Manitoba s Aging in Place Long Term Care Strategy has helped seniors and others receive health care services in their homes or in communitybased, home-like settings. However, as our population grows older, it is timely to review the existing Aging in Place strategy. We must ensure there are appropriate local support services to match the needs of seniors and their families. We also want to help people avoid unnecessary loss of independence due to premature admission to personal care homes or hospitals. Like other Canadian provinces and most developed countries, Manitoba has an aging population. Like other jurisdictions, we face associated challenges, including increasing chronic disease, rising health costs, competition for health care workers, inconsistent quality and access to health care services, and new, expensive technologies and treatments. In February, 2011 the province presented a renewed long term care plan (Manitoba Health, 2011) to meet growing demands for services for seniors; including more choice, more independence, better quality of life This document supports the renewed long term plan; incorporating strategies for both aging in place at home and for long term care. It covers the continuum of care that may require someone to move from their single-family home to a retirement community, then onto supportive housing and later, a personal care home. As seniors make these transitions, Advancing Continuing Care proposes innovative solutions to keep seniors healthy by providing integrated, seamless care through a wide range of community-based services. This implementation plan includes seven areas for action and related objectives. The seven action areas are: 1. helping individuals to stay at home by investing in community supports and focusing on wellness, capacity-building and restoration when delivering home care services 2. improving access to home care services 3. strengthening and promoting co-operation among health care partners to keep people at home 4. strengthening and expanding options for community-based housing as alternatives to personal care homes 5. ensuring there are enough long term care beds to meet the needs of Manitobans June 2013 Final (Pre Communications Document)

2 6. developing new, innovative ways of delivering services to improve health outcomes for residents of personal care homes 7. committing to dedicated health technology to help improve the quality and coordination of care and in making informed decisions and policy As Advancing Continuing Care is implemented, all actions will follow four themes: Individuals receiving health services will be included in all decisions related to their care. There will be closer co-ordination and communication between different sectors of the health care system to help prevent gaps in care. Care programs will emphasize restoration to allow individuals to live as independently as possible. All actions and decisions will be in the best interests of the individual. Implementation of Advancing Continuing Care will ensure the sustainability of the health care system through efficiencies and effective service delivery in order to maximize the health and quality of life of Manitoba s aging population. It will maintain the viability of our health care system by substituting home and community-based services for more expensive long-term care or acute care services and result in better care for Manitobans, allowing us to age in place, with the right services at the right time. Introduction Currently, about 169,000 Manitobans are age 65 or older (ex: 13.6 per cent of the population). This number is expected to almost double by 2036, while the number of people aged 20 to 64 will increase by only 35 per cent (Doupe 2010). As we think about how to address the needs and maximize the health and well-being of our aging population, a key concept that has emerged is successful aging (Edward 2006). This concept emphasizes healthy lifestyles and daily routines, social supports, exercise and autonomy to allow older people to maintain their health and independence for as long as possible. If we are to commit to successful aging for our seniors, will need to change how our continuing care programs are structured and delivered. Advancing Continuing Care focuses on matching the needs of individuals and their caregivers with appropriate local support services to avoid unnecessary loss of independence and quality of life through premature admission to higher care personal care homes or hospitals. Change is critical to improve the lives of Manitoba seniors and others with chronic illnesses and disabilities and to help ensure the sustainability of the overall healthcare system. This implementation plan was developed by Manitoba Health in collaboration with many key stakeholders. To ensure a comprehensive approach, the department consulted representative provincial committees, government departments, regional health 2

3 authorities, private agencies, advocacy and interest groups and individual practitioners. Participants in the consultation process were able to discuss ideas, share information and help develop the plan. Advancing Continuing Care is a blueprint for the province to follow over the next five years. It is a realistic plan for achieving results and creating the environment necessary to encourage and support stakeholder commitment and sustain long-lasting change. Background Over the years, Manitoba has been a Canadian leader in introducing new, innovative services to help its residents remain in their homes as they age (ex: Home Care program and a Primary Caregiver Tax Credit). We have also improved the quality of services for residents of personal care homes through initiatives such as monitoring standards compliance and enhanced staffing guidelines. Aging in place or aging in the community is a lifestyle that supports the following inherent values: safety and security living with reduced risks in the home flexibility adjusting services to meet changing needs choice freedom to choose among options equity equal access for all seniors dignity ability to maintain a sense of self worth (Manitoba Health 2006) In 2006, Manitoba introduced the Aging in Place Long Term Care Strategy which focused on home-based services to help individuals with their daily activities or health needs, as well as explaining supported housing options. New and enhanced Aging in Place options included: supportive housing (SH) supports to seniors in group living (SSGL) specialized supports (SS) personal care homes (PCHs) (See definitions for explanations of these various types of housing.) Capital investment since 2006 reflects the emphasis on keeping people in their own homes: In 2007, there were 5,490 PCH beds in Winnipeg and 4,168 PCH beds outside Winnipeg (Manitoba Health 2007). Since then, there has been very little change in the number of PCH beds. Manitoba Health 2012 Bed Map identifies 5,566 PCH beds in Winnipeg and an additional 4,116 beds outside Winnipeg. (Manitoba Health 2012a) PCH bed projections are anticipated to be quite stable (growth of approximately five per 3

4 cent a year) until 2021, when the first of the baby boomer population reaches age 75. At that time, demand for PCH beds will start to grow more dramatically (Doupe 2010). As of March 31, 2012, there were 516 SH units in Winnipeg and 274 units outside Winnipeg. This is a significant increase from the 250 units in Winnipeg and 48 units outside Winnipeg in place prior to implementation of the 2006 Aging in Place Strategy (Manitoba Health 2012b). Since 2006, more than 3,500 units of SSGL and 113 spaces offering SS for individuals with complex needs have been established (Manitoba Health 2012c). As the population ages and health care costs rise, it is timely to refresh the Aging in Place Long Term Care Strategy. Trends, Challenges and Opportunities Manitoba Health conducted an environmental scan to determine the most significant trends, challenges and opportunities affecting the continuing care sector. The scan captured both factual and subjective information through a comprehensive literature review, including the February 2011 Report from the Manitoba Centre for Health Policy on Population Aging and the Continuum of Older Adult Care in Manitoba. It also included consultation with key internal and external stakeholders. The environmental scan confirmed that Manitoba is facing many of the same challenges experienced by other jurisdictions: an aging population, increasing chronic disease, competition for health care workers, variation in timely, equitable access to health care services, inconsistent quality, rising costs and new, expensive technologies and treatments. Through the environmental scan, Manitoba Health identified four key subjects that need to be addressed: demographics service provision human resources health system Specific areas for action, objectives and plans were then developed to address each of these four subjects. Demographics The number of Manitobans requiring continuing care services is expected to increase significantly in the coming years. It is likely we will see a growing demand for home care, high rates of institutionalization, a shortage of affordable housing with supports and families that will have difficulty coping with parental needs (Doupe 2010). We also anticipate the choices that tomorrow s seniors make will likely be different than those of today s 4

5 seniors, with baby boomers tending to exhibit stronger preferences for independent living arrangements, greater autonomy and choice in services (Conference Board of Canada 2011). While Manitobans today are typically healthier and more independent longer in life, our aging population is changing our view of health care and forcing us to consider ways to remain self-sufficient in our homes for as long as possible. The greatest users of homebased care are seniors, defined as individuals aged 65 and over. According to a recent Statistics Canada report, 42 per cent of Canadian seniors aged 85 or older received homebased care, compared to 20 per cent of those aged and eight per cent of those aged 65 to 74 (Roterman 2006). Despite the amount of home care provided, many seniors living at home reported unmet needs. Almost one in five seniors, who used a combination of both formal and informal home care, reported unmet needs (Roterman 2006). It is expected the number of seniors requiring home-based services will rise dramatically as the population ages. Based on past utilization patterns, and taking into account the aging of the baby boomer generation (ex: those born between approximately 1946 and 1964), the demand for long term care will also increase exponentially. The majority of PCH residents in Manitoba are 75+ years old. Growth in this segment of the population will be quite modest until 2021, after which time it will increase markedly. From 2027 to 2036, the number of 75+ year olds living in Manitoba is expected to almost double. Population projections are expected to vary widely between regional health authorities (Doupe 2010). Chronic diseases predominantly occur in later life and the increase in the number of elderly Manitobans means these diseases will be more prevalent in future years. The aging population and associated escalation of chronic disease will greatly affect the health care system and its sustainability. Chronic diseases are now the major cause of death and disability worldwide. Currently, four in five seniors living at home have at least one chronic condition, compared to one in 10 of those between the ages of 25 and 54 (Canadian Home Care Association 2011). Having chronic conditions also increases the likelihood of being hospitalized, receiving home-based care or transitioning to a PCH. Because of immigration in previous decades, the ethnic and linguistic profile of Manitobans is also changing. Ethnic and linguistic diversity among those aged 75 and older will increase, thereby confronting the long term care sector and the continuing care system more broadly with new challenges. Innovative approaches, greater sensitivity and more support services will be required (Conference Board of Canada 2011). Service Provision Because the healthcare system is illness-oriented, it is not clear what successful aging looks like. Presently, the system focuses on reacting, treating and curing and not on improving health outcomes (Canadian Health Services Research Foundation 2011). As a result, there are many questions around the value and sustainability of the current system and how it is funded. 5

6 There is a growing body of literature that indicates home-based care can improve the quality of life and can often be a cost-effective substitute for PCHs and hospital care. However, there must be an emphasis on capacity-building, increased flexibility and access to a broader range of services. To support the desire of individuals to age at home, manage their chronic conditions at home, or care for family members at home, there must be timely access to appropriate community-based services. These services may include long term care, preventative/restorative care, acute care and palliative care. The various players in the health care field also need to work together to ensure individuals have access to home care services, regardless of their demographics or where they live (Canadian Home Care Association 2011). Conversely, the most appropriate place for individuals is not always in the home. Quality health care depends on accessing the right care in the right place at the right time. There is an important role for hospital and long term care services when individuals have high care needs or are very ill. If the care intensity becomes extensive as expressed in the number of hours of care, the number of service providers or necessary equipment home care expenditures may become more costly than facility-based long term care. The merits of facility-based care (PCH) versus home-based care are not an either-or proposition. Facility-based care and home-based care each occupy a critical place along the healthcare continuum. We need both sectors to be well-managed, well-staffed, well-funded and wellfunctioning (Canadian Healthcare Association 2009a) Currently, the institutional model focuses on tasks, schedules and processes related to illness. It stifles innovation and is associated with poor outcomes for residents, frustration for family members and an unsatisfying work environment for staff (Canadian Healthcare Association 2009a). In the future, bureaucratic traditions in personal care homes must succumb to cultural transformation. For this to happen, we must devote less energy to creating additional regulations and more attention to processes that will help transform long term care facilities into desirable places to live and work. Personal Care Homes should be reflective of home life and adhere to the fundamental values of dignity and respect. The consumers and baby boomers of today will be the residents and families of tomorrow. They will not accept institutional settings, structured schedules, rigid dining hours and waiting for care. Privacy, respect, flexibility and the right to manage one s own risk should be the cornerstones of facility-based long term care services. Cultures of caring will assign greater priority to the psychological, social and spiritual elements of life (Canadian Healthcare Association 2009a) Human Resources Health care needs cannot be met without adequate human resources to carry out frontline services. Staff shortages in home care programs and personal care homes are chronic and well-reported. Recruitment, retention and access to a stable, consistent, appropriately trained workforce is one of the most critical issues facing the continuing care sector (Provincial Aging in Place Working Group 2011). Unfortunately, human resource challenges will only become more severe as the population ages, demand and complexity of service needs rise, and the 6

7 labour pool shrinks. The continuing care sector must be equipped to meet the needs of residents with more complex health challenges, support efforts to move patients out of acute care and implement community housing options that allow seniors to age in place. Yet, current staff and skills shortages already limit the capacity of workers providing direct care to respond as effectively as they would wish to client/resident needs. For long term care facilities, staffing levels were the second most frequently identified sources of concern for direct care workers in Canada, at 57.3 per cent (Banerjee 2011). Staff working in long term care report feeling their work is not as valued as work in acute care (College of Nurses of Ontario 2007). To effectively attract and retain more people in long term care, there needs to be a re-evaluation of the entire sector. An awareness campaign targeted at staff and potential new recruits, emphasizing the variability of the work and the skills required to deliver increasingly complex care in facilities, would help foster a greater appreciation of the work done in long term care. Health System How health care systems are organized and structured can have a significant impact on how effective, efficient and cost-effective they are. No one would disagree with the call for accessible, safe and high quality care and yet, the realization of this goal is challenging (Canadian Home Care Association 2011). Factors that compromise the goal include: funding mechanisms that focus on distinct programs and care processes, rather than an individual s care outcome lack of integration and the fragmentation of healthcare delivery systems for individuals with ongoing or long term care needs lack of recognition or support for the role of informal caregivers inadequate information exchange between practitioners, health sectors, clients and families limited availability of technology in many regions (Hollander 2007) Integration of health services is driven by aging Manitobans who typically develop longterm chronic conditions and require the health system more often and for a greater length of time. The nature of chronic conditions is that they are complex and associated with many co-morbid complications. Integration between facility-based long term care, home-based care and primary care has been demonstrated to achieve improved health outcomes for these clients. These community-based partnerships require information technology tools to support communication and improve adherence to established clinical practice guidelines (Canadian Home Care Association 2011). Critical Elements of Advancing Continuing Care There are three critical elements that, together, provide the framework of this implementation plan foundational factors, supporting themes, and areas for action. Figure 1, adapted from British Columbia Provincial Health Services Authority Strategic Plan, illustrates the interdependent relationships between these three elements 7

8 and the connection to Manitoba Health s vision healthy Manitobans through an appropriate balance of prevention and care. Foundational Factors An implementation plan requires a strong foundation upon which an organization can launch action plans and achieve desired outcomes. The following factors are instrumental to the success of Advancing Continuing Care Provincial Policy guides service delivery, influences and sets the tone for initiatives and direction. Policy review is inherent in implementing the plan. Organizational Capacity refers to the governance, structures, management and leadership necessary to support research, clinical service, education and training activities. Specifically, this refers to the capacity staff have for learning, the capacity of information systems to support operations and research, the infrastructure capacity of programs to implement new initiatives and the financial capacity available to fund new initiatives or practices. Partnerships allow for collaboration and the achievement of goals. Anticipated partnerships include: clients and families as partners in care the regional health authorities other government departments/provinces as partners in health care planning and policy development private organizations as partners in health care planning and delivery advocacy and special interest groups research and academic organizations as partners in knowledge creation and learning Communication/education is necessary to promote an integrated continuum of care and to ensure clients and their families are aware of health care options. Health care providers must also provide education and leadership to enable clients, informal caregivers, service agencies and members of the general public to be involved in defining and evaluating programs. Supporting Themes Within Advancing Continuing Care are supporting themes that cut across all areas of the implementation plan: Navigation of the Health System Individuals receiving health services must be included in all decisions related to their care. For clients to be effective partners in decision-making, the system needs to be more streamlined, integrated and co- 8

9 ordinated. Health care providers need to foster a culture that values the consumer voice and should serve as coaches, navigators or teachers for consumers. To achieve this, it is important that processes focus on the client, rather than the provider.(harrison 2002) Effective Transitions Seniors are particularly vulnerable to the lack of coordination and communication between different sectors of the health care system. Recent hospitalization and poor transition planning following discharge from acute care is a known precursor of loss of independent living. This frequently occurs because appropriate supports to enable a long-lasting discharge are not planned and communicated to the next caregiver. An integrated and effective health care system addresses the transition points of care and works to ensure safe and consistent bridging of services or sectors (Ontario Home Care Association 2007). Rehabilitation/Restorative Care Care programs must include: an emphasis on capacity-building and rehabilitation to maintain or promote an individual s ability to live as independently as possible, with the overall aim to improve functional independence, quality of life and social participation. an emphasis on a person-centred approach to care, which promotes clients wellness, active participation in decisions about their care and cultural sensitivity by health care providers provision of more timely, flexible and targeted services to maximize the client s independence Culture of Caring Data collected should focus not only on costs, but also on best fits for clients and successful initiatives. Provision of care and services should be personal and proactive anticipating the client s needs, reducing risk, improving efficiency all with the empathic intention to improve healing in body, mind and spiritual elements of life (Ball 2010). Client/family experiences are made up of a continuum of events some positive, some negative. In promoting a culture of caring, it is critical to find and eliminate the negative or those things that get in the way of the positive experience (Ball 2010). Areas for Action Taking into account the current situation, information from stakeholders, and current trends and evidence, Advancing Continuing Care includes seven specific areas for action: 1. helping individuals stay at home by investing in community supports and focusing on wellness, capacity-building and restoration when delivering Home Care services 2. improving access to Home Care services 9

10 3. strengthening and promoting collaboration among health care partners to keep people at home 4. strengthening and expanding options for community-based housing as alternatives to personal care homes 5. ensuring there are enough long term care beds to meet the needs of Manitobans 6. developing new, innovative ways of delivering services to improve health outcomes for personal care home residents 7. committing to dedicated health technology to help improve the quality and coordination of care and in making informed decisions and policy The seven areas for action and accompanying objectives align with Manitoba Health s priority areas of capacity-building, health system innovation, improved service delivery, and improved health status and reduced health disparities among Manitobans. The action areas were developed in collaboration with other representative departments, regional health authorities, programs, health care providers, stakeholders and individuals. Ideas and recommendations from other provincial strategies or initiatives have been incorporated where appropriate. 10

11 Figure 1 Manitoba Health Vision Healthy Manitobans through an appropriate balance of prevention and care Advancing Continuing Care Areas for Action Helping individuals stay at home by investing in community supports and focusing on wellness, capacity-building and restoration when delivering Home Care services Improving access to Home Care services Strengthening and promoting collaboration among health care partners to keep people at home Strengthening and expanding options for community-based housing as alternatives to personal care homes Ensuring there are enough long-term care beds to meet the needs of Manitobans Developing new, innovative ways of delivering services to improve health outcomes for PCH residents Committing to dedicated health technology to help improve the quality and coordination of care and in making informed decisions and policy Supporting Themes Navigation of Health System Effective Transitions Restorative Care Culture of Caring Foundational Factors Provincial Policy Organizational Capacity Partnerships Communication/Education 11

12 AREA FOR ACTION #1: Helping individuals stay at home by investing in community supports and focusing on wellness, capacity-building and restoration when delivering Home Care services Without any further improvements in our health and community care systems, it is unlikely there will be any deceleration in the growing demand for Manitoba Home Care services. A number of systemic issues apply across many jurisdictions, such as an aging population, an increase in the number of clients remaining at home with complex care needs, difficulties accessing long term care, shorter hospital stays and more outpatient and day treatments, the projected decline in family care as more women enter or remain in the workforce, and the lack of a stable or skilled workforce to meet the increasing complexity in service needs (Ryburn 2009). A rehabilitative and restorative approach for the delivery of Home Care is proposed, both to reduce dependency on Home Care and to improve our capacity to cope with the growing demand for service. Facilitating Manitobans wishes to age in their community requires investment in a wide range of home and community-based services (Provinical Aging in Place Working Group 2011). An individual s community can mean a neighbourhood private home or a variety of supportive living arrangements within their broader community. Home Care services need to be better aligned to seniors requirements and resources need to be used more to provide seniors and informal caregivers with care and support tailored to their needs. This will help solve health system problems and requires an overall shift in emphasis to the Home Care program (Canadian Healthcare Association 2009b). Shifting resources from the acute care health system to an integrated continuum of care will allow people to age in the place of their choice with the right services at the right time (Canadian Healthcare Association 2009b). Objective 1.1 Strengthen the Home Care program/increase and Enhance Home Care Services There needs to be a greater investment in community resources, including home-based care, so that seniors who are at-risk can stay home or return to the community following a hospital stay. The Home Care program s capacity and infrastructure needs to be strengthened and enhanced to ensure success. This could be achieved by increasing the limit on the maximum number of hours of Home Care service, based on client need, to provide greater flexibility in allocating services. Enhancement of services also depends on a stable, competent and reliable workforce. Previously, difficulty recruiting and retaining direct service staff has caused service disruptions and delays in responding to service requests. It has also been difficult to hire staff with the appropriate skills to meet clients service needs. As the acuity levels and complexity of clients needs continue to rise, the number of highly skilled direct caregivers will need to be increased (Canadian Healthcare Association 2009b). Traditionally, Home Care case managers focused on services within the client s home and community. When individuals were not eligible for Home Care services, they were referred to other providers or left to care for themselves, until the next episode of need. This narrow 12

13 and episode-specific approach often results in fragmented care and is not compatible with current health care pressures. A broader scope for Home Care in managing chronic disease requires moving from a traditional case management model where activities are primarily focused on the client s episodic need within the home and community to an approach that considers the client s/caregiver s experience in the context of their broader needs across the health care continuum (Canadian Home Care Association 2007). Action Plan Enhance education and training for Home Care workers related to a restorative and rehabilitative approach and the increasing complexity of care needs Develop a Continuing Care Human Resources Strategy to address anticipated increasing complexity of client care needs Increase Home Care service limit hours, based on assessed need, to facilitate greater flexibility in service allocation Develop an enhanced role for Home Care case co-ordinators that helps clients navigate through the health care process and ensures the effective, efficient use of resources. To support this effective case management strategy, specific Home Care actions should include the following: Align Home Care case management with primary health care teams to build strong partnerships and achieve better integration and accountability between the services of case managers and/or frontline clinicians and family physicians. Broaden the eligibility criteria for Home Care to proactively support clients to better manage their own conditions. Build partnerships with community resources to improve collaboration among client care services. Incorporate evidence-based clinical guidelines for managing chronic disease to improve consistency of care across the primary health care team (Canadian Home Care Association 2007). Objective 1.2 Introduce greater flexibility and options in delivery of Home Care and community services The Home Care program has garnered a high degree of support in the health care field and from the general public. The majority of Canadians (80 percent) support the development of more home and community care programs as a way to strengthen the health care system (Canadian Healthcare Association 2009b). As well, Home Care consumers and external stakeholders have indicated a need for more flexibility, access to different options including short-term and specialty home care services, and more autonomy for consumers in managing and coordinating their own home-based services. The finding that home-based care is a lower-cost alternative to facility care does not automatically imply that investments in the Home Care program will be cost-effective 13

14 (Hollander 2009a). Investments in home and community care can only increase overall cost effectiveness if these investments are made in the context of a broader integrated system of care in which home care can be substituted for facility care and hospital care. Integrated systems of care provide seamless care across a wide range of services. The result is effective transitions, broad system-based policies, positive economic outcomes due to substituting less costly home care services for more expensive long term care or acute care services and, most importantly, better care to clients (Hollander 2009a). The Canadian Health Service Research Foundation 2011 report Better with Age: Health Systems Planning for the Aging Population stated, While an emphasis on the value of home care as an appropriate and less expensive cost alternative to acute hospital care was part of the 2004 Health Accord, the implementation of the concept has not gone very well or been totally successful. In large part, the lack of success is due to the fact that home care is evolving to be more acute care-focused, rather than focused on the needs of individuals with chronic conditions, who may require support services. It is argued that pressures on alternative levels of care are a result of the erosion and revamping of home care since the 2004 Health Accord (Canadian Health Services Research Foundation 2011). A potential risk in focusing on short-term and specialty home care is that the definition of home care will shift in the minds of policy makers and the public to equate it with provision of intense, specialized, short-term services post-hospitalization or prior to placement in a long-term care facility (Hollander 2009a) Proportionally, savings are greater at the lower levels of care, especially in maintaining clients at an optimal level of functioning and preventing further deterioration in health status. Studies have shown that it is as important to give attention to longer-term maintenance/preventive home care as it is to short-term, post acute home care. Noted Canadian authority Marcus Hollander and his colleagues used data from various jurisdictions to identify the cost savings of various models of care. One study provided evidence that maintenance/preventive home care services reduce health expenditures throughout the entire health service continuum and that cost savings extend over a period of years. In fact, a client s health status is often stabilized by preventing deterioration in functional status over time (Hollander 2002). No one service home, community or facility-based long term care is automatically the best option for every person. The challenge is to find the right balance between home care, community services, supportive/assisted living services and facility-based long term care. Action Plan Expand/develop innovative, diverse community options. Develop service funding models that meet the needs of specific communities or individuals with specialized needs. Examples include contracting with agencies for specialized services, service purchase agreements with housing providers and co-ordination/case management agreements between programs, departments or private agencies. The Home-Based Enhanced Shared Care Model (see definitions) is particularly useful in rural regions where there are limited resources. For clients with diverse and complex care needs, the model facilitates service 14

15 provision through partnerships among programs, departments and agencies. The Home-Based Enhanced Shared Care Model includes: specialized training for staff, based on individual client service needs clustering of clients to ensure effective use of human resources clearly defined co-ordination and case management processes Expand or develop Program Integrated Managed care of the Elderly (PRIME) (see definitions). PRIME enables elderly individuals requiring comprehensive support to remain at home, delaying admission to a PCH. Similar programs in other jurisdictions have been successful in maintaining the health status of participants, slowing their health decline and improving their quality of life. Implement transition units (see definitions) or Early Supported Discharge programs (see definitions) to reduce the number of Alternate Level of Care patients (see definitions) in acute care beds. Program participants may return home or transition to long term care. Transition units may also accept medically stable emergency department clients or individuals living in the community who are unable to function safely at home (Reference Objective 4.1). Enhance Self-/Family-Managed Care (see definitions) program criteria, infrastructure and funding model to promote improved participation and access to the program. Develop increased capacity to provide quality end of life care services to clients in their homes or alternate community settings. Expand the community model increasing hospice spaces, increasing staffing and diversity of positions for inter-professional teams, enhancing technology use, such as Telehealth and 24-hour, on-call service to improve access and consultation services for urban and rural care providers. Enhance bereavement services, especially for children. Provide more palliative services for people with non-malignant diseases. Expand palliative services for specialized and marginalized populations with high care needs. Review paneling process to ensure it is standardized across all regions, reflects an integrated system of care, and that clients are accessing the housing option most appropriate to their needs. Objective 1.3 Enhanced caregiver support As a result of a policy and societal shift away from institutional care, more people are being cared for in their homes and communities. This is creating an increased demand for family care. The Canadian Caregiver Coalition defines family caregivers as providing care and assistance for spouses, children, parents and other extended family members who need support because of age, debilitating medical conditions, chronic injury, long term illness or disability (Canadian Caregiver Coalition 2008). Informal caregiver and family caregiver are terms that refer to unpaid individuals, such as family members, friends and neighbors, who provide 15

16 care. These individuals can be primary or secondary caregivers, full-time or part-time, and can live with the person being cared for or live separately. Family caregivers are the invisible backbone of the health and long term care system in Canada. According to the General Social Survey (2007), about one-fifth of Manitobans aged 45 and over reported helping a senior experiencing physical or other limitations due to a long term health condition (Manitoba Government 2011). There are more than two million informal caregivers in Canada, and a recent conservative estimate of their economic contribution was $25 billion (Canadian Institute for Health Research 2010). Many of these caregivers are providing critical support to seniors who are living at home with complex health conditions, or are providing critical support to family or friends with special needs who are living at home. Providing care for a family member, neighbour or close friend can be very fulfilling and rewarding. However, in some cases, caregivers experience distress and burnout, which has consequences for the home care client, the informal care provider and the health care system as a whole. As a result, caregivers may be unable to continue in their roles. If there is no other family member or friend to assume the caregiving, the senior is more likely to require admission to a long term care facility. Interventions to reduce caregiver burden have the potential to improve the quality of life for both the client and caregiver and reduce inappropriate or premature admission to long term care (Hollander 2009b). In recognition of their contribution, the Government of Manitoba introduced The Caregiver Recognition Act in May These caregivers provide a valuable service to their families and to their communities, and in many cases; it comes at a physical, emotional and sometimes, financial cost to individuals and families (Manitoba Government 2011). The legislation recognizes both the value of their contribution and the need to work with caregivers to provide a network of supports. Action Plan Review primary caregiver tax credit processes and provide recommendations to government. Review and enhance delivery of in-home and outside-the-home respite services including: service plans that reflect both client and caregiver needs, including increased flexibility and availability of respite services assistance in navigating and accessing health care services tailored to the diverse needs of caregivers caregiver education and training programs to help caregivers fulfill their roles in a sustainable and safe manner 16

17 Objective 1.4 Restorative approach It has been argued that traditional home care programs are often not as successful as they could be because they lean too far towards an outdated dependency model of service, rather than focusing on activity, independence and successful aging. Restorative approaches to home care that improve both functional and social status, can reduce dependency on the service and improve our capacity to cope with the growing demand for care. Literature shows that seniors who received restorative home care after an acute illness or hospitalization had a greater likelihood of staying at home, required less service in the long term and had a reduced likelihood of visiting an emergency department than if they received usual home care services (Ryburn 2009). Such restorative approaches aim to go beyond traditional home care goals of maintenance and support toward improvements in functional status and quality of life. Restorative programs include services that maximize an older person s potential within the recovery process. As a result, they either prevent the need for hospital admission or post-hospital transfer to long term care, or appropriately reduce the required level of ongoing home care support (UK College of Occupational Therapists 2010). A restorative approach typically refers to intensive, time-limited, inter-professional home care services developed for people with poor physical and/or mental health, to help them learn or relearn the skills necessary to manage their illness and to maximally participate in everyday activities (Ryburn 2009). A range of rehabilitation programs have been developed and evaluated. Programs vary widely in their structure, staff skill mix and nature of interventions. However, they share general principles (ex; focus on helping people to do rather than doing to or for, identify expected outcomes, define maximum duration). Each program typically provides a comprehensive assessment and time-limited plan of rehabilitation in the client s own home (Social Work Co-operative 2010). There is particularly strong evidence that occupational therapy and health education, often undertaken by nurses visiting people at home, contribute to improved functional and health status. Treatment plans include various combinations of exercise and training, behavioural changes, environmental adjustments, adaptive equipment, counselling and support, training and educating patients, families and friends, adjusting medications and recognition of the importance of the social support aspect of home care. The emphasis is on a social care model, rather than a medical model of rehabilitation and restoration (Ryburn 2009). More work is needed to evaluate the most effective types of restorative programs. Questions remain about which clients are likely to benefit most from a restorative approach and the most effective duration and timing of restorative interventions. It is recognized that positive outcomes are likely to be considerably less for clients with more limited potential to be independent (Rablee 2011). In relation to specific components of the restorative approach, evidence suggests that comprehensive occupational therapy interventions may have a positive impact on the social ability and quality of life of older adults and that participation in physical programs can often have a positive impact on psychosocial health (Ryburn 2009). 17

18 Regional health authorities are in the beginning stages of designing and implementing rehabilitation pilot projects that reflect the needs and resources in each of their jurisdictions. The projects focus on maximizing an individual s independence, resulting in a reduction in the need for ongoing service support and potentially delaying or preventing a move to a long term care facility. The pilot projects are varied and include rehabilitation programs related to preventing falls, maximizing independence of supportive housing residents, implementing or expanding community stroke services and services to individuals whose functioning is compromised by chronic disease and are being discharged home from hospital. An example of an established community program that is representative of the restorative approach is the Winnipeg Regional Health Authority s (WRHA) Community Stroke Care Service. The program provides case co-ordination, home care support and rehabilitation for clients discharged after a recent stroke. Benefits include increased functional independence and mobility, decreased risk of falls and post-stroke complications, decreased long term reliance on Home Care and prevention of premature institutionalization for some clients. The Community Stroke Care Service was initiated in June Since that time, there has been a positive impact on client outcomes and use of resources, including annual increases in the number of admissions, decreases in the average length of stay and increases in the percentage of clients discharged home (Winnipeg Regional Health Authority 2011). This emerging body of evidence suggests that a restorative approach to home care has significant advantages over the traditional approach, which is aimed only at maintenance and support. For adults whose health and functional status is compromised, providing timely interventions, education and assistive technologies to help them resume independence and activity appears, in many cases, to be effective in reducing demand for ongoing services. Implementing restorative approaches into Home Care services will also more closely align the program with recent models of healthy aging. Action Plan Develop and test a restorative model of home care that focuses on improving clients functional outcomes, while meeting their health care needs. Key features of the Restorative Home Care Model: Program would be accessed through referral to Home Care. Initially, only new clients would be assigned to the restorative program. Initial in-home assessment would be completed by rehab professionals (ex: physiotherapists, occupational therapists) with occupational therapists as the lead clinicians. Comprehensive assessments would ensure services are tailored to best suit the complexity of the client s needs. There would be a strong emphasis on functional assessment. The concept of functional status refers to an individual s ability to attend to his/her daily activities and to fulfil his/her social roles in the most satisfying way. The assessment of functional status 18

19 addresses all aspects and components of function. Function is seen as the result of the interaction between health status and contextual factors, including both environmental and personal factors. It goes beyond a medical condition (World Health Organization 2001). Services would be provided based on a clinical care map/protocol. Goals would be set, in collaboration with the client and family, using a case management approach. At the completion of the intervention, a decision would be made about whether the client would be discharged, continue on the restorative program, or be referred to the regular Home Care program. The role of Home Care direct service staff would change from providing care to clients to supporting clients to maximize their independence and engagement. This is a substantial philosophical shift and requires initial and ongoing training for Home Care staff. The role and competencies of the Home Care Co-ordinator would change. Health education would become a more important focus. The Restorative Home Care Model may focus on different target populations (ex: fall prevention, clients being discharged from hospital, new referrals, maximizing client function to delay PCH placement, etc.) AREA FOR ACTION #2 Improving Access to Home Care Services Since the early 1990 s, home care programs have evolved and grown in response to changes in the acute care sector with shifts in bed use, increased ambulatory care clinics and day surgery and limitations in the long term care sector, such as waiting lists for beds and limited availability. Through this evolution, home care has emerged as an essential element of the health care system. Research shows that the health care delivery system in rural and remote areas faces unique challenges compared to urban centres (see definitions). A 2008 scan of rural and remote home care programs (including Manitoba) was undertaken by the Canadian Home Care Association and highlighted the main issues impacting service delivery. Those issues included a lack of health human resources (ex: physicians, nurses, practitioners and home support personnel), lack of support systems and local resources resulting in unnecessary client use of acute facilities, limited transportation and requirements to travel long distances and hours to see very few clients. As governments shift their policy focus from provision of care in an acute care setting to provision of care closer to home, it is critical that home care policy planners and administrators understand the challenges of providing this care in rural and remote settings (Canadian Home Care Association May, 2008). Technology also enables access to health care and is an important means for more effectively and efficiently serving the broadly dispersed population. The potential of technology to improve access to care, care delivery and provider support is significant. Accordingly, rural and remote settings of care need to become the priority for technology investment. The health care consumers of today expect services to be readily available and 19