After decades of systemic issues, time to finally overhaul Alberta long-term care, experts say
Pandemic has exposed impact of years of 'benign neglect': researcher
In May 2005, Alberta's auditor general released a long-awaited report on the state of the province's continuing-care facilities.
Fred Dunn's findings confirmed what health-care advocates and opposition politicians said was already widely known: long-term care facilities weren't complying with all of Alberta's housing and care standards — standards that were themselves outdated.
Nearly one-third of the audited facilities failed to meet basic care requirements for residents. Administrative problems ran deep. At one facility, management told staff to wash and dress residents who were already awake as early as 3 a.m.
Fifteen years, four governments and one government task force later, Alberta Health Services (AHS) is still not ready for an audit on the deficiencies Dunn identified in 2005 and his successor reiterated more specifically in a 2014 follow-up recommendation.
"That speaks volumes to the inability that we have seen with governments in this province to actually address some of the issues that we have seen in seniors care for decades now," said Sandra Azocar, executive director of Friends of Medicare.
She said while systemic issues in long-term care predate the coronavirus, "through a pandemic it just has become even more clear that Alberta Health Services, and the way that we treat our seniors, is not up to par."
Monitoring care at the resident level
The auditor general's recommendation relates to AHS properly monitoring care at the resident level. Dunn's 2005 criticisms predate the health authority's existence; instead, they mentioned the nine regional health authorities existing at the time, which consolidated in 2009 to form AHS.
In the 2014 report, auditor general Merwan Saher found the health authority had significantly improved its long-term care monitoring since 2005. But he said most of the increased provincial oversight focused on facilities' internal processes and administration, not the care they provide.
Alberta Health Services' monitoring still couldn't answer critical questions. Are residents fed properly and at the right times? Are they kept clean or forced to sit in their own urine and feces? Do they have people to talk to? Perhaps the most telling indicator of all: Are they happy?
Saher recommended that AHS create systems to periodically verify that long-term care facilities provide residents with an adequate number and level of staff every day, and that they implement individual care plans and meet residents' basic needs.
The health authority declined an interview request from CBC News but said it has enhanced its long-term care monitoring since the 2014 auditor general's report.
It said work on just one section of the report is outstanding, though it remains unclear whether the work AHS said it has done would fully satisfy the auditor's recommendation.
Staffing level concerns
For example, Saher found AHS did not have a proper way to periodically verify that the daily scheduling of staff at long-term care facilities, for every shift, was enough to meet residents' needs.
In an emailed statement, AHS spokesperson James Wood told CBC News that facility operators must disclose audited staffing information to AHS and Alberta Health through annual reporting. This information has to show compliance with Alberta's Nursing Homes Act and the operator's service contract with AHS, he said.
Under the Nursing Homes Act regulations, facility operators must provide residents with an average minimum of 1.9 paid hours of combined nursing and personal services every day. At least one nurse has to be on duty or on call at all times, and at least two nursing and personal services employees (which can include nursing assistants) must always be on duty.
When asked how the health authority independently ensures proper staffing levels, Wood said a team audits continuing care facilities to assess compliance with the province's Continuing Care Health Service Standards.
Those audits, he said, are performed about every two years. And the health service standards do not specifically address staffing.
Paid staff hours vs. direct care hours
Azocar said there is a "huge difference" between the paid hours outlined in the Nursing Homes Act regulation and hours of direct care that residents receive.
"When people are on holidays, when people are sick, when people are away for whatever personal reason," she said, "and they are not able to provide the direct care, the [facility] operator still gets paid. But no care is being provided."
The regulations represent "almost a race to the bottom," she said.
In the 2014 report, the auditor general said that AHS does not set a single minimum staffing ratio for all long-term care facilities. Instead, its funding model allows it to set staffing level requirements for facilities based on the care needs of residents, which are measured with a standardized assessment tool used all over the world.
The health authority determines how much funding a long-term care facility will receive. It also sets a minimum number of hours, by staff level, that the facility must employ in the coming year.
That doesn't ensure the right number and level of staff are always scheduled, however.
"AHS does not have an adequate system to verify how facilities allocate the staff hours they are funded to provide," the report said.
"The only way to directly verify that facilities properly distribute funded care hours is through periodic review of facility staffing schedules and through unannounced facility visits — neither of which is performed."
Delayed launch for staffing audit tool, AHS says
Wood said the only section of the 2014 auditor general's report that AHS has not yet implemented relates to verifying staffing levels at facilities.
"AHS has developed a risk-based, random audit process to periodically verify staffing," he said, adding it allows AHS to compare monthly employee time sheets against paid hours in facilities' payroll systems.
"This process will add one more level of assurance that the minimum required staff is present each day at facilities to provide care," Wood wrote.
He said AHS had anticipated launching the tool late in 2019-20, but "factors, including the COVID-19, situation have moved back the timeline."
The updated launch date is late 2020-21, he said.
Moving beyond a minimum level of care
"The issues in long-term care go back at least to the '60s and they have tended to be focused around quality of care," said Carole Estabrooks, a University of Alberta nursing professor and researcher.
Estabrooks is scientific director of Translating Research in Elder Care (TREC), a research partnership program that studies long-term care and how to improve quality of both life and care.
One of the challenges with long-term care, she said, is the nebulous space it occupies in Canadian society.
"We really don't know where long-term care belongs in the system," she said. "It is not part of the health system, really, but it is viewed as part of the health system. It is provincially governed; it is not part of the Canada Health Act.
"So it has not really got a solid home."
But she said the long-term care system has also suffered from "benign neglect."
"We have done a patchwork approach to things and haven't really had a comprehensive, bottom-up redesign," she said, adding that with the coronavirus pandemic, the public has seen the system "explode."
Over the years, resources for long-term care have not kept pace with demand, Estabrooks said. Training for facility staff varies across the country. And employees — often older women and immigrants — are vulnerable themselves, excluded from the decision-making process and prone to stress burnout.
Estabrooks said Alberta needs to commit to redesigning its long-term care system. At the centre of those discussions need to be residents, caregivers and facility employees, she said, and the focus has to shift beyond simply providing a minimum standard of care.
"When you get up in the morning, even if you have dementia — which 80 per cent of the old folks in nursing homes do — do you have some meaning?" she said. "Is there some purpose? Do you want to live that day?"
She said Alberta, like other provinces, cannot afford to keep applying a patchwork approach to long-term care because "that doesn't get at systemic, foundational, fundamental problems which is I think what [the coronavirus pandemic] is going to force us, in a very urgent way, to look at."
COVID-19 outbreaks at facilities
As of Monday afternoon, 364 residents and employees at long-term care facilities have contracted the virus, which is especially deadly for older and immuno-compromised people. Of those, 43 have died — more than a third of the province's total deaths. A total of 275 have recovered.
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AHS has temporarily taken over or transferred control of two privately run facilities experiencing outbreaks: Manoir Du Lac in the northern Alberta town of McLennan, and Millrise Seniors Village in Calgary. Officials said staffing levels, outbreak protocols, and quality of care were issues of concern at both facilities.
In another 2019 follow-up report, Auditor General Doug Wylie reiterated that without provincial monitoring of adequate staffing levels, every day and every shift, "AHS cannot ensure that residents it places at long-term care facilities are safe and have access to the right care at all times."
In early February, the UCP government announced it had struck a stakeholder panel to review Alberta's continuing care laws, with the goal of creating one piece of overarching legislation.
"The new legislative framework will support a more responsive system that is better able to meet the needs of Albertans, while eliminating unnecessary barriers and reducing red tape," a government news release said. "It is expected to be tabled in 2021."
Azocar said it is critical that the province implement the auditor general's recommendations and finally fix the issues that have beset long-term care for decades.
"So that we don't hear stories about seniors sitting in soiled Depends or incontinence supplies because there are no staff to help them out," she said, or "being treated as if they are in some kind of production line by one staff [member] trying to feed six or seven seniors."
'Almost unbearable to watch what is happening'
COVID-19 has underscored the consequences of not reforming long-term care, Estabrooks said.
"People are dying because of their vulnerabilities at extraordinary and unprecedented levels in nursing homes," she said.
"But they are not just dying — they are dying alone. They are dying without family; they are dying afraid. And they are dying, often, without the basic necessities."
Beyond that, Estabrooks said, it is about the "value of a life" and whether people believe, as those in her research program do, that a long life nearing its end matters as much as those with many years left.
"If we really believe that, this is almost unbearable to watch what is happening."
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