Caring for Canada’s seniors will take our entire health care workforce

Much of the focus on the health care needs of Canada’s aging population surrounds the shortage of physicians with expertise in care of older adults. But the country’s 75,000 licensed physicians represent only a small part of the Canadian health care workforce. By contrast, there are approximately 360,000 regulated nurses, 35,000 social workers, 30,000 pharmacists, 17,000 physiotherapists, 13,000 occupational therapists and 10,000 dietitians in Canada, and about 90,000 personal support workers employed in Ontario alone. Improving care for Canadian older adults will undoubtedly require educating and engaging the entire health care workforce.

Retooling the Canadian health care workforce

The Ontario Ministry of Health and Long-Term Care recently released a comprehensive report focused on improving care for older Ontarians. The December 2012 document entitled Living Longer, Living Well: Recommendations to Inform a Seniors Strategy for Ontario highlighted how “Ontario’s health, social, and community human resources need to be better prepared and supported to meet the needs of our aging population.” In fact, this was recognized as a necessary enabler to supporting a seniors strategy for the province.

Developing geriatric competence in all health and social care professions

The Ontario Seniors Strategy is clear about the geriatric competence of the province’s health care workforce. “The fact that we don’t require any of our schools in Ontario that train our future health, social, and community care providers to formally teach content related to caring for older adults is concerning.”

Overall, information is lacking on the geriatric content of Canadian non-physician health and social care training programs. The best studied is the nursing profession, which appears to have an overwhelming underrepresentation of teaching on care of the older adult.

Nurses represent the largest sector of Canada’s health care workforce, and there are approximately 60 registered nursing training programs across the country. Despite the fact that approximately 80% of schools claim to integrate gerontology within curriculum, gerontological nursing educators are not convinced that this is being properly taught.

“The problem is that there are very few faculty in nursing that have a specialized expertise in gerontology; the content is mostly taught by non-experts,” notes Dr. Lynn McCleary an Associate Professor of Nursing at Brock University. “That’s easier to do when you know where to find the latest best evidence. But that just isn’t the case in gerontology,” notes McCleary, the current president of the Canadian Gerontological Nursing Association. “There just aren’t enough specialty people.”

Indeed, a 2008 survey of the gerontological content in Canadian nursing programs, revealed that only 2.4% of faculty with master’s degrees and 6.0% of faculty with doctoral degrees had a gerontological focus. Another Canadian study published in 2002 reported that only 8% of clinical hours had a focus on the nursing care of older adults and only 5.5% of students chose geriatrics for their final clinical practical prior to graduation.

Dr. Sandra Hirst, an Associate Professor of Nursing at the University of Calgary and past president of the Canadian Gerontological Nursing Association, says that senior’s health is still not a priority among nursing programs.

“There’s not a lot of faculty members with interest in senior’s health,” she notes. And when Hirst and her colleagues have advocated for a more integrated curriculum that focuses on the unique needs of older adults, the response has generally been one of “not interested and not a priority.”

Another complicating factor is the negative images of gerontological nursing amongst nursing faculty and students. In fact, Dr. Sandra Hirst says that “faculty members and their attitudes towards seniors health,” represent the biggest barrier to building capacity in gerontological nursing education.

The challenges faced by the nursing schools in Canada—a shortage of educators with specialist expertise, a lack of prioritization, and pervasive negative attitudes—are not unique. Many other Canadian health and social care professional schools, including pharmacy and social work, are experiencing similar difficulties.

Accordingly, one of the Ontario Senior Strategy’s key recommendations is that the Ministry of Health and Long-Term Care in collaboration with the Ministry of Training, Colleges and Universities require “core training programs in Ontario for physicians, nurses, occupational therapists, physiotherapists, social workers, pharmacists, physician assistants, paramedics, personal support workers and other relevant health and social care providers include relevant content and clinical training opportunities in geriatrics.”

And Dr. Samir Sinha, the provincial lead for the Ontario Seniors Strategy, says that since the release of the strategy he has been approached by educational leaders from several of the province’s health and social care professional schools.

“I think what’s been heartening is that since the release of the strategy, I haven’t met a dean of a school of a physical therapy, nursing or medicine that doesn’t agree that we don’t need to more, and that we need to address this issue now,” says the Director of Geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, Ontario.

Lynn McCleary is also optimistic. “We’re not where we need to be but mostly the leaders are pretty aware of the issue,” she says. Another promising sign is that several faculties of nursing across the country have established Canada Research Chairs in Healthy Aging including the University of Alberta, McMaster University and Memorial University.

 “I’m feeling positive about us moving ahead,“ says McCleary.

The expanding role of paramedics

Beyond developing competence in care of the older adult, the Ontario Seniors Strategy was clear that preparing the health care system for an aging society would require some thinking outside the box. One strategy highlighted was the expansion of the roles of many members of the health care workforce.

In Ontario, paramedics have taken up this challenge with impressive results.

Older adults are the highest users of paramedicine services in Ontario, accounting for more than half of all 911 calls. The majority of these calls are for non-urgent issues, with over 40% of all ambulance transports to an emergency department being potentially inappropriate. As the population continues to age worldwide, there is an ever-increasing demand for emergency medical services, with requests for emergency ambulances rising by as much as 8% annually.

Recognizing these challenges, the field of “community paramedicine” has emerged in the 21st century where the traditional paramedic role is expanded to include the management of urgent, low-acuity illnesses and injuries.

A 2013 systematic review of community paramedicine practices revealed that research is lacking, but promising programs exist in the United Kingdom, Australia and here in Canada. The one published randomized controlled trial reported that older adults randomized to a community paramedicine intervention in the United Kingdom had reduced emergency department visits and spent less time in the emergency department. The intervention was also cost-effective.

In Ontario, community paramedicine programs are emerging in Hamilton, Ottawa, Niagara, Toronto and Renfrew County. In the County of Renfrew, close to 60% of all 911 calls come from patients over the age of 60, while over 25% of total calls come from patients over the age of 80. Additionally, like many other jurisdictions in Ontario, a substantial proportion of the Renfrew County’s acute care hospital beds are occupied by elderly patients waiting for long-term care placement.

In response to these challenges, in 2007 the County of Renfrew Paramedic Service in Deep River, Ontario launched the Aging at Home Program. The initiative is a partnership between community paramedics and the community’s long-term care facility (North Renfrew Long Term Care) that provides housekeeping, maintenance and personal support worker services. The program runs 24 hours a day, and community paramedics provide a broad range of services including: periodic health assessments, medication dispensation, vital sign monitoring, client education, fall prevention, home safety assessments and routine blood work collection.

The Aging at Home Program has a roster of 32 frail community-dwelling older adults with an average age of 87, who would otherwise reside in a long-term care facility. The initiative is supported by the Ontario Ministry of Health and Long-Term Care’s nearly $1.1 billion investment in community-based care for seniors, called the Ontario’s Aging at Home Strategy.

Emerging evidence suggests that this model of care can provide seniors and their caregivers with significant quality of life and satisfaction, while reducing emergency medical service utilization as well as acute care hospitalizations. Additionally, the Deep River Aging at Home Project is very cost-effective when compared to long-term care by reducing the daily costs per resident from $169.66 per day to $54.66 per day. Moreover, unlike long-term care residents, clients of the Aging at Home Project are not required to provide co-payment.

Michael Nolan, the Chief of the Paramedic Service and Director of the Emergency Services Department for the County of Renfrew, says the program has been “overwhelmingly positive.”

Nolan, who is also President of the Emergency Medical Service Chiefs of Canada, emphasizes the patient-centredness of this model of care.  “We advocate on your behalf and augment your deficits and the things that you need the greatest amount of help with to allow you to stay at home for as long as possible.”

Personal support workers are starting to meet the challenge

Canada’s personal support workers or PSWs are also pursuing expanded roles to meet the needs of an aging population. Personal support workers provide much of the direct care to seniors residing in the community and long-term care settings, helping them with a broad of services including home management and personal care. Approximately 90,000 personal support workers are employed in Ontario, and demand for these skilled workers is expected to double in the next decade.

Personal support workers have traditionally operated within a custodial model of care, a task-oriented paradigm, where essential tasks are simply performed for dependent clients. However, there is growing evidence from the field of rehabilitative sciences that the provision of custodial care can actually create further dependence among frail seniors.

This is in contrast to a restorative paradigm, in which individuals are “assisted to maximize their ability to engage independently in everyday living and social activities, rather than simply having essential tasks done for them so that they can remain living in their homes.”

Personal support workers who provide restorative care are trained in issues relevant to rehabilitation, organized into a coordinated team and instructed to reorient the focus of their home care from “taking care of patients” to “maximizing function and comfort.”

 “The more custodial care we provide, the less able that person becomes or can become,” says Lynelle Hamilton, the Director of Personal Support Worker and Supervisory Programmes at Capacity Builders, the training and management support division of the Ontario Community Support Association.

“It’s the ‘if you don’t use it, you lose it’ philosophy,” says Hamilton.

“The discussion about supporting a person to function at their optimal ability seems to stop just a level short of PSWs,” Hamilton notes. “We talk a lot of nursing and physiotherapy interventions, but there’s a not lot of discussion about PSWs and the role they can play.”

Indeed, a published review of restorative home care services around the world revealed that this model of care has been developed and tested in the United Kingdom, the United States, New Zealand and Australia. However, the review was unable to identify any similar developments in Canada, and concluded that the current model of home care services “appear to be limited to maintenance or substitution for long-term or acute care.”

Outside of Canada, there is strong evidence supporting restorative home care services. A 2002 prospective trial of nearly 1,500 older adults receiving an acute episode of home care compared those provided with restorative care to those provided with usual care. Compared with usual care, restorative care was associated with a greater likelihood of remaining at home and a reduced likelihood of visiting an emergency department. Additionally, restorative care patients had higher levels of self-care, home management and mobility at completion of home care services.

Lynelle Hamilton believes that we are not providing Canadian PSWs with either the training or the time to provide restorative care.

“We spend tons of time training PSWs how to make a bed and give a bed bath; we need to shift that over and look at care of the rest of the person,” says Lynelle Hamilton. “We also know that PSWs don’t have the time they feel they need to spend with a client to support wellbeing.”

But there are definite signs that things are moving in a positive direction. The Community Care Access Centre (CCAC) of the Toronto Central Local Health Integration Network (LHIN) piloted a quality improvement project called “Changing the Conversation” in the summer of 2011. The project was designed to pursue a more restorative approach to care by allowing service providers to deliver a more flexible and customized care experience. Personal support workers were reoriented to move from a “task first” to “talk first” approach.

Towards interdisciplinary learning and care for the older adult

When asked about the care of frail older adults in the community, Dr. Jocelyn Charles, the Chief of Family Medicine at Sunnybrook Health Sciences Centre, says she’s “just so frustrated.”

“The care of these patients is so complex that no one provider has the answer; yet our health care system is set up so that a patient goes through a series of consultations and the hope is that someone puts this all together,” says Charles.

“In the past it’s been geriatricians who’ve been trained to pull this all together,” she notes. “But there aren’t enough geriatricians to provide this.” Charles notes that this now often falls on the family physician, and she says “it’s becoming unmanageable.”

Charles also notes how taxing this can be on the patient and their caregivers and family members. “The poor patient is the one who has to go from office to office and test to test like a pinball in a pinball machine,” she comments.

The health care system’s response to Charles’ frustrations has been the development of interdisciplinary collaborative models of care that attempt to reduce health care fragmentation and duplication.

And Charles is helping lead such a model. “What we need is real-time consultations with all the providers in the circle of care present so that we have a discussion with the patient and all of us present about what are the patient’s needs and preferences and what are the strategies that we can pursue,” says Charles.

The result? The IMPACT (Interprofessional Model of Practice for Aging and Complex Treatment) Clinic initiated in 2008 at the Family Practice Unit at Sunnybrook Health Sciences Centre in Toronto, Ontario. The intervention has since spread to 2 additional family health teams in the Greater Toronto Area.

The IMPACT intervention is a 2-3 hour appointment where elderly patients with complex health needs meet with a multidisciplinary team including: the patient’s own family physician, a community nurse, a pharmacist, a physiotherapist, an occupational therapist, a dietitian and a community social worker. The goal of the intervention is for the team to work together with the patient and caregiver in real-time to “unpack” the patient’s medical, functional and psychosocial health care needs.

“It’s truly real time collaboration and learning together,” says Jocelyn Charles. “When you think about the complexity of some of these patients…they need us to come together and put in some collaborative time and effort.”

Initial evidence reports that the IMPACT intervention is feasible, effective, well received and portable across different primary care settings.

The model is also designed to accommodate trainees from each of the various disciplines. This allows for health and social care professional students to train together, something the Ontario Seniors Strategy has also recommended.

The Canadian health care workforce’s coming of age?

The Ontario Seniors Strategy and the Canadian Medical Association’s recent call for a national seniors health care strategy, represent a real opportunity to reform our health care workforce for an aging population.

Emerging models of care and education from across the country highlight that by developing competence, expanding our roles, and working together, the health care system can optimally meet the needs of Canada’s seniors. With growing demand and support from governments, policymakers and the public itself, the Canadian health care workforce may be finally coming of age in order to better care for our older adults.

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  1. Tom Closson

    I think the heading for this article (Caring for Canada’s seniors will take our entire health care workforce) is bit extreme. Only a a small percentage of seniors require a significant continuing intervention by the health crare workforce. Most seniors only require intermitent support from the health care work force and do quite well on their own with the support of family and friends.

    • Jeremy Petch

      Fair enough, Tom. I think what we were trying to get at is that it requires all types of practitioners. Too often, when this issue is addressed it’s only discussed in terms of physicians and supply of geriatricians. We wanted to highlight that all health care professionals have a role to play. Clearly not our best worded title!

    • Nathan Stall

      Dear Tom,

      Thanks for your thoughtful comment. I certainly agree that most seniors age successfully with the support of their families, social networks, and primary care providers. Indeed, only 4.8% of older adults are consistently high users (with an additional 6.8% being inconsistently high users) of inpatient hospital services ( The title of this article is meant to reflect the fact that the entire health care workforce will need to be educated and engaged in order to optimally meet the needs of Canada’s seniors. This builds on the Institute of Medicine’s landmark 2008 report, Retooling for an Aging America: Building the Health Care Workforce (, which concluded that “the definition of the health care workforce must be expanded to include everyone involved in a patient’s care.”

      Hope that clears things up!


    • Carolyn Hudson

      I’m disappointed that someone with Mr. Closson’s experience with the Ontario Hospital Association and provincial ministries would deny the existence of a crisis in healthcare for seniors in Ontario.

      MOHLTC is not addressing the lack of geriatricians and, in my experience, provides sporadic physiotherapy support for seniors with mobility issues.

      %featured%Seniors are a demographic who do not feel comfortable complaining or asking for more, so many survive with 30 minutes of daily homecare begrudgingly provided by a private, for-profit company which squeezes as much labour out of its poorly trained PSWs as it can get away with.

      And the fact that a lack of LTC beds keeps seniors in hospitals for up to 18 months is unconscionable.

      Family and friends are getting tired%featured%, Mr. Closson; time for the well-paid MOHLTC bureaucracy to fix the system.

  2. Tom Closson

    I believe that we need to a better job in serving seniors who have significant needs. %featured%The point I am making is that we need to recognize that most seniors have minimal needs that they can either address themselves or with the help of their family and friends. The small number of seniors with significant needs are the seniors that the system needs to focus on.%featured%

  3. Mark MacLeod

    Perhaps it is worth noting that seniors of the past are not the seniors of the future. In fact, the seniors of tomorrow are the baby boomers of today. What are the implications of this for the health care system given the political force that the boomers have become used to wielding? I suspect it means that marginal demands on health care will increase , not only for core and emergent services but in the vast sea of services now under the umbrella of health care.

    To put all boomers in the same basket is over simplistic – the early boomers are not the same as the tail boomers – differences in wealth accumulation, pensions etc mean that early boomers have greater means to provide services for themselves that many tail boomers simply will not. What the impact of the financial circumstances will be is likely anyone’s guess however in the event that health services provided publicly are reduced some boomers will have ability to self pay and many will not.

    David Foote of Boom Bust and Echo told us all of this as far back as the 70’s. That we suddenly are “discovering” the coming impact of the boomer population becoming high proportion consumers of health care speaks not to our insightfulness, but our penchant to selective listening.

  4. Rees Moerman

    Medicare in Canada has degenerated into ‘mediscarce’ … or chronically rationed services/clinical resources. The real issue seeking solutions is not age-in-place but “care-in-place.” The only long term geriatric resolution will be technological as most other efforts have myopically focused on the three failing money pits, which are high cost care-labor, big silo’ed hospital edifices, and poly-pharmacy. Tertiary clinical-care as a default to extra-mural medical specialties is often confusingly referred to as home-care… which it in fact does not truly function as such. Geriatric home-care must evolve into a ‘hospital-at-home’ with improved real time access via tele-medical innovations, ADL’s abetted by assistive technologies, vitals monitoring for health assessments to enable skilled decision makers to can safely provide minute-to-minute care needs in one’s home aided by family members.

  5. Georgina Black

    The title may be a bit dramatic but the messages about retooling the workforce to provide quality care to the elderly are key. Changes to the workforce need to be supported by informed and engaged patients, families and volunteers. This includes finding the courage to have difficult conversations about end of life care.

  6. Nicole McLoud

    My mother (an American) claimed that she had to go to a Canadian hospital to be treated for pneumonia (while traveling to Alaska) and was told by the doctor that she was lucky to be an American because if she were a Canadian citizen at her age (70) they would not be allowed to prescribe her the antibiotics she needed to recover. My mother asked if elderly Canadians even could purchase antibiotics and was told no. When she asked the doctor what were elderly Canadians supposed to do if they got sick, they doctor replied “Die”. I find this to be very hard to believe but my mother swears to it. This supposedly happened a few years ago. Is there any truth to this?

    • Andreas Laupaics

      Hi Nicole. I can assure you that elderly people in Canada have access to antibiotics and a vast amount of health care. The suggestion that elderly people in Canada who need health care are left to die is ridiculous. My 87 year old mom is more concerned that her doctors want to test her blood sugars too often, rather than not often enough.

  7. Tina R

    I think that there is really a big problem in Canada with seniors being able to find good doctors for them. My grandma and grandpa have always had trouble being able to find a good doctor, a couple years ago they got a doctor but he was a quack! He misdiagnose my grandma and she ended up with heart problems so sever that she was revived four times in the hospital after her heart stopped. Just recently her doctor took her off her heart medication for no reason and now she is sick. A month or so ago my grandpa started to see a new doctor and this doctor was very nice and explained everything to my grandpa and always had a solution for problems and my grandpa was amazed because he wasn’t used to it! There is great doctors in Canada available, but seniors seem to have a hard time finding them or they are not excepted because of there age.

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