Reinventing the Old Folks Home

The Tyee.caLast week, with absolutely no fanfare, the B.C. government formalized changes that will make a huge difference to the way care is provided to thousands of senior citizens throughout the province.Health Services Minister Colin Hansen issued no news release, but on May 14 sent a letter to all the regional health authorities, telling them that effective that very day, new legislation governing assisted living would come into effect.But whether the changes will make life better or worse for B.C. seniors remains a question. The answer may, in the end, depend very much on the physical and mental health of the individual senior, as well as the specific facility into which he or she is placed.What 'assisted living' meansThe new legislation specifically mandates for the first time the use of "assisted living residences" for thousands of seniors. "Assisted living residences" provide some help for seniors living in them, but also a great deal more independence for their senior residents than do current long-term care homes or chronic-care hospitals. The official definition requires an assisted living residence to provide for its residents: housing, "hospitality services" such as meals and laundry, and one or two of a list of "prescribed services" ranging from help in taking medications to help with such basic chores as going to the bathroom. But in all cases, the seniors themselves are to be considered capable of directing their own care.Advocates for the new system argue that in the past many seniors have been forced to live in long term care homes too early. Although able to do many things for themselves, they've been hurried into clinical settings geared to providing round the clock medical care without much privacy. That, the experts say, is not optimal for the seniors' physical or mental health, quite apart from the fact that such institutions are much more expensive to run than assisted living facilities.Under the government's new plan, that expensive and intrusive long-term residential care now is reserved for just the most ill, those needing what is called "complex care."Linda Mueller, a public affairs officer with the health services ministry, told The Tyee that many seniors don't need the intensive care. An 85-year-old today may need no more care than a 75-year-old did a few decades ago.Groups see new gaps in Alzeheimer's careBut seniors' groups are warning the new approach appears to be fraught with problems. One of their biggest concerns is that although the Liberals have pledged to create a "continuum of care," there appears to be a big gap in the middle, between those who can genuinely benefit from an assisted living set-up, and those who will be considered ill enough to qualify for the new "complex care" model.One of the biggest concerns is those elderly residents who are developing Alzheimer's disease or other forms of dementia, illnesses that may make it impossible for the seniors involved to genuinely direct their own care. Logically, you might think that a person with dementia shouldn't be deemed capable of directing their own care.But the government's own papers on assisted living make it clear that a certain amount of dementia is to be expected to at least some of those residing in the assisted living facilities."Where an occupant has some impairment of cognitive function," says the ministry's paper on health and safety standards, "the ministry's 'personal services plan (required for each resident) will address safety and security issues specific to this impairment. Families members will be consulted where appropriate."Police and social workers know from experience that dementia often poses a risk to a senior's own health and safety, especially if the dementia takes the form of wandering away from the residence, and becoming lost, distraught, and/or confused.No clear method to gauge riskHowever, the government's view is that these seniors should be allowed to assume voluntarily some such risks. "In this housing model," says the same paper, occupants are able to make personal choices about the level of support and risk they wish to accept in order to maintain their independence."What isn't spelled out is how the operator or the government determine whether a person is thinking clearly enough to be able to decide to take those risks in an informed manner.Joyce Jones, co-chair of the Seniors Network of BC, notes that long-term care facilities had special secured units for Alzheimer patients."Now there is complex care and assisted living," said Jones, who is 74 and lives on her own. "There is no such thing as intermediate level."Ironically, the Independent Living BC Program (ILBC), a housing-for-health partnership that involves the provincial and federal governments, regional health authorities, and the private and non-profit sectors, was created to fill a gap in healthcare between homecare and residential care.Beds target halfway thereBut the BC Health Coalition and other groups have expressed concern that in any case, new facilities aren't going up fast enough to meet the demand. Health authorities are closing some of their long-term care beds before suitable replacements are in place.The Liberal government's New Era platform vowed to create 5,000 new spaces for seniors by 2006. Of that number, 3,500 units would be allocated to ILBC for the creation of independent and assisted living units. The other 1,500 spaces are to be allocated as needs arise, although several are going to benefit palliative care.Now, two years away from the set completion date, 1,938 units across the province or 55 per cent of the target has been achieved. That figure includes the recent announcement, in partnership with the Vancouver Island Health Authority, of 363 new assisted living units for several developments in new buildings in Victoria, Courtenay, Duncan and Saltspring Island, and conversions in Parksville and Saanich.Jones says another problem that seniors in the new assisted living facilities are facing is that their lives may become surprisingly costly. Although the units are all subsidized by the government, Jones says people in her organization have found that fees at assisted livingfacilities can get very high as seniors' medical needs increase, and they are forced to pay personally for more and more aspects of their care.This leads to another aspect of concern with the assisted living set-up - the lack of regulation of the units and of a way for the residents to complain about many aspects of their care. Instead of being licensed, with health authority staff performing regular inspections and responding to complaints, the new facilities will have only to be "registered" with a new provincial registrar. Residents or their families will be able to make a complaint to the registrar - but only if it deals with a specific health or safety issue. At the moment, there's no way at all to complain about dreadful meals, poor levels of maintenance or price-gouging - although the government is promising that such a system will bedeveloped.Harder to stay at home, seniors sayIn the meantime, many seniors on waiting lists for government-subsidized services are struggling to continue living in their homes.Starting in 2001, the provincial government began curtailing funding to home support services, such as housekeeping. Terrie Hendrickson, coordinator of the BC Health Coalition, says that as a result of these cuts most seniors get less subsidized help for the services they may need to help them stay in their homes, such as cleaning, housekeeping or grocery shopping."If you need help with bathing you can get home support, but they may be bathing you in a dirty  bathtub," Hendrickson said.She notes that people who are cut off from home support often decline quicker and are sicker when they enter the healthcare system. Hendrickson believes that by maintaining the previous level of home support services, the government could save twice as much as it puts in.Questions about converting facilitiesEven when existing long-term care facilities are converted into assisted living units, some conversions result in as much as a 20 percent reduction in beds. That's because wards that housed a few residents are renovated to make way for self-contained units complete with individual washrooms and kitchenettes.But David Plug, a spokesman for the Fraser Health Authority (FHA), which last month announced plans to create 369 more assisted living units, says that number is misleading because some units are occupied by couples.Health authorities say that many of the long-term care facilities being torn down or renovated are 25 years old and more, and their building design is obsolete. In some cases, the washrooms aren't accessible for walkers or wheelchairs. Sometimes ceilings need to be reinforced for the safe operation of ceiling lifts that help lift patients from their beds and put them into their wheelchairs.Jones agrees that some facilities are old and need to be replaced. But that, she says, doesn't mean that when they are closed, that whole gap in services for those who need an intermediate level of care should open up.'Time of transition'Mueller admits a time of transition in the system always poses some difficulties. "There is the perception that residential care facilities are being closed, but many will benefit from new facilities," the health services ministry spokesperson said. "This is one of the difficulties in atransition period. We are in the process of developing beds in response to needs and demands of communities."But seniors groups still fear that the needs and demands of some groups of seniors are being left out of the mix altogether.Vancouver journalist Brenda Jones last wrote for The Tyee about Todd Bertuzzi's image problem.

Barbara McLintock is the Victoria-based contributing editor to The Tyee.