Fase IV | Retrospectiva

Culture change is a movement that emphasizes home and work environments where: • Care and resident-related activities are directed by residents

• The physical environment is designed as a home

• Close relationships exist among residents, family members, staff and the community • Job design supports and empowers all staff to respond to residents’ needs and preferences • Management enables collaborative and decentralized decision-making

• Systematic processes are comprehensive, measurement-based and used for continuous quality improvement.

Newer models feature self-contained environments where trained and empowered universal workers provide person-centered care to a small group of 10 or fewer residents who live together, eat together and receive services tailored to their specific needs and preferences. Most models emphasize technologically smart physical spaces with built-in safety features and medical technology, and private ensuited rooms clustered around a central area with a shared kitchen, dining and living areas. Culture change has not been rigorously evaluated but early results are promising. Some researchers note that as nursing home residents become more disabled and require higher levels of care, some medical characteristics of traditional nursing homes may be more appropriate and could be compromised by primarily social models of care.

The Artifacts of Culture Change tool developed by the US Centers for Medicare & Medicaid Services contains a comprehensive set of practices adopted by pioneering nursing home and assisted living facilities. A user-friendly online version of the tool is available at www.artifactsofculturechange.org.

• Day/night dementia care

• Health and personal support services for older adults including comprehensive health assessments, podiatry, oral care, blood pressure monitoring, diabetes management, bathing, nutritional counseling and specialized diets, exercise programs, mental health, addictions and grief counseling, immunization clinics, speech, occupational and physiotherapy, etc.

• Community outreach including home visits, special diet meal delivery, telehomecare and transportation in defined catchment areas

• Caregiver training on care of older adults with complex chronic conditions • Advanced placements for social work and health sciences students. The Expert Panel believes that these services can be delivered cost-effectively in long term care but substantial policy development and analysis will be required, ideally with significant input from the sector. Service and capacity planning models will need to take into account:

• Geographical variation in demand due to aging, health status, socio- economic factors, rurality, cultural diversity and availability of family caregivers to provide heavy care.

• Supply of ‘spaces’ in day/night programs and ‘places’ in a variety of settings including retirement homes and supportive housing.

• Models of service organization and delivery that ensure safety, quality and efficiency. For example volume thresholds to maintain staff competency and reduce cost per unit of service; technology to ensure access to specialist consultants; a referral-based admissions process and connections to centres of excellence to improve flow and quality of care; and more flexible operational models (i.e., hours of operation, length of stay) to better address the needs of different types of residents.

• Costs and benefits for government, consumers and providers, including the impact of various options on equity of access to publicly-funded services.

In the near term, LTC homes could improve care for existing higher acuity residents if they had better access to specialized behavioural supports, portable laboratory and diagnostic testing, and advanced Emergency Medical Services similar to the Extended Care Paramedic Project in Nova Scotia. Long term care is becoming a care setting for increasing numbers of people with severe mental illness and complex psycho-social needs. Further dialogue is required on what can reasonably be expected of the sector or alternatively, what resources and policy changes will be required to enable long term care to adequately address the needs of these residents.

WaLker rePorT

reCommeNdaTIoNS

• The LHINs and CCACs should ensure that seniors are provided with timely Assess and Restore/Transitional Care in LTC homes, while waiting for their first LTC home choice, in order for patients to have an opportunity to regain previous levels of function and to prevent deterioration. • The ministry should build incentives

for LTC homes to have the flexibility to address surge capacity.

To move forward, the Expert Panel recommends that the Ministry of Health and Long-Term Care work with the LHINs to:

• Develop a comprehensive service capacity plan that meets local needs and works across LHIN boundaries

• Generate cost-savings by targeting system improvements in areas such as palliative/end of life care, prescription drug utilization, stroke and diabetes management and dementia care

• Invest in community capacity to care for residents requiring episodic or less intensive care and services

• Support cost-effective care delivery in a wider range of assisted living settings

• Explore service delivery models that improve LTC utilization and optimize lengths of stay based on need and evidence

• Establish a residential care sector table and process to review delivery models and determine the pricing of new programs and services

• Develop a standardized contract format for new services to promote efficiency in administration and certainty for the provider

• Move to an outcomes based performance and accountability framework that allows providers more discretion to determine how care is provided while holding them accountable for reporting on, and meeting agreed