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.