Canada’s older population (5.9 million) now outnumbers its younger counterparts, 14 and under (5.8 million) (Statistics Canada, 2017). As outlined in Figure 1. the older population (65+) will continue to grow significantly in the coming years. This substantial increase among the older population has caused many to question what impact it will have on Canada’s health care system. As the older population continues to grow so will the demand of health care services (Canadian Medical Association, 2013). We are only at the beginning of a population shift and we are already experiencing challenges in facing the needs of an aging population. For this post I will reflect on my professional practice in home and community care with respect to the aging population while explaining the foundations of Ontario’s health care system.
Overcrowding of hospitals has forced near emergency responses due to a lack of resources and ability to safely provide care (Mulligan, 2019). According to Ontario’s yearly health system report in 2016/17 approximately 4,233 hospital beds were used by patients who were awaiting some type of alternate level of care and could not be released as they had no other place to go (Health Quality Ontario,2018). Making improvements to home care can help alleviate some of the pressures on hospitals by enabling older adults to actively age in their own homes longer.
Funding and Legislation in Ontario
As guided by the Canada Health Act the province of Ontario is responsible for making decisions regarding health care services, delivery and expenditures. In Ontario, the Ministry of Health and Long-Term Care defines how tax payers receive health care services across the province. Most basic health services are publicly funded through the government. Nearly 667,000 people in Ontario receive publicly funded home care per year (Health Quality Ontario, n.d). Presently 14 Local Health Integration Networks (LHINs) are the health authorities responsible for regional administration of public healthcare services in the province (LHIN, 2014).
Recent change of Ontario's health system has caused a shift in direction resulting in the restructuring of the LHINs which are being replaced by ‘Health Teams.’ Figure 2. displays the idea behind shifting toward health teams in order to provide a more unified and integrated approach to providing care. “Ontario Health Teams are groups of health care providers and organizations that are clinically and fiscally accountable for delivering a full and coordinated continuum of care to a defined geographic population (Ministry of Health and Long-Term Care, n.d).” A foundational aspect of Ontario’s new health teams is the emphasis on inter-professional connectedness. As the aging population continues to grow older adults will have more complex health issues and interdisciplinary teams will be key in providing quality care. The Ontario Hospital Association (2019) has determined that in order to make improvements the province may need to remove certain existing legislative, regulatory and/ or policy barriers. This process includes the integration of various health professionals, users of the system, and community to develop and create the best possible strategies for an optimized health care system (Canadian Inter-professional Health Collaborative, 2010).
Health of Canadians-Understanding Determinants of Health
The hope with Ontario’s new ‘health teams’ is to ultimately improve collaboration and communication between hospital, in-home and community care teams. Health teams will enable patients to be move involved in their own care and care plan ultimately allowing them to better navigate throughout the system (Ministry of Health and Long-Term Care, n.d).Allowing patients to be a part of the care team can allow them to better understand ‘what is health’ and give health care providers a better understanding of the individual and the care that they need. Health care professionals must understand the how the social determinants of health interplay with the health outcomes of patients as these factors can can affect our vulnerability within the health care system. In doing so we learn that factors such as our level of education, our income, where we live, the quality of our early childhood experiences and the physical environment that surrounds us are what guide our health outcomes throughout our life course. These factors are often unchangeable and can be the root cause of poor health outcomes throughout the life course (Health Canada, 2018). These factors can cause differences in health influencing modifiable and unfair social disadvantages (Ministry of Health and Long-Term Care, 2018).
Over 87% of older Canadians prefer to live in their homes for as long as possible (Home Care Ontario, 2018). Many older adults require home care services in Ontario, however, not all Ontarians have equal access to home care services (Office of the Auditor General of Ontario, 2015). This causes health disparities among Ontario's population and impacts the overall population health. For example, one’s inability to access health care services due to geographical location can not only influence poor health outcomes but cause other health issues such as social isolation.
Multilevel Approaches to Understanding Health
Due to complexities associated with individual health in relation to social determinants of health, health care professionals, and policy makers utilize various health models to better understand health behaviors and improve health outcomes. For example, the ecological model can be used to explain the health issue of social isolation in older adults living in the community. This can be useful for home care service providers and other health care professionals to understand the what experiences and exposures influence social isolation in older adults. By using ecological model to address social isolation we can understand how multiple levels within the health system influence our health outcomes at different stages in our life. This can guide health professionals develop strategies to decrease and/or prevent social isolation in older adults. This model demonstrates multiple levels of health influence based on individual risk factors at five levels (micro to macro) as displayed below in Figure 3.
While social isolation occurs at the level of the individual, the negative health outcomes further impact multiple levels of health and “interventions to reduce social isolation must act on the structural determinants, including economic disadvantage and discrimination, as well as supporting the immediate needs of socially isolated and/or lonely individuals (NSC, 2016).” As explained in the video below social isolation can also be a risk factor for other health conditions including Alzheimer's Disease (Malcom, Frost & Cowie, 2019).
Chronic Disease prevention and management
In Ontario, chronic disease affects approximately 80% of individuals over the age of 45, and is the leading cause of death and disability (MOHLTC ,2007). The demands of patients with chronic disease are increasing and require integrated and collaborative approach (Van Dogen et al., 2016). Mental illness (14%) is the most common condition causing the need of home care services followed by injuries (10%), aging needs (9%), cardio-vascular disease (9%), arthritis (8%) and cancer (8%) (Statistics Canada, 2015).
The existing model behind home care is to provide nursing and personal support visits to help manage chronic disease and other illnesses (Health Quality Ontario, 2013). Self-management strategies an integral role in supporting older adults to remain in their own home for as long as possible. Promoting self-management strategies for those with chronic disease receiving home care can decrease possible risk of other poor health outcomes such as falls. By engaging older adults to have a role in their care through self-management the individual and health care system will benefit (Health Quality Ontario, 2013). For example, if an older adult with chronic arthritis maintains regular exercise they are less likely of being at risk of falls causing hospitalization then those who do not exercise. Home care can allow older adults to remain in their homes longer, prevent hospital visits, and help self-manage chronic disease and other illnesses (Home Care Ontario, 2019).
Vulnerable populations
Relevant to my role in home care it is important for service providers to identify vulnerable individuals in order to reduce health inequities and better serve the older population. However, there is a lack of policies and structures in place that help home care providers specifically assess individual vulnerabilities (Canadian Nurses Association, 2010). According to Seniors First BC the three main risk factors that contribute to vulnerability in older adults include: health status; cognitive ability; and social network. Depending on the status of one’s social determinants of health and their experience throughout the life course as the individual surpasses 65+ they can become vulnerable economically, financially, psychologically and socially. A study on vulnerable seniors outlined that older women are at higher risk of being vulnerable than men and this can worsen if the individual lives alone or has a chronic disease (United Way Ottawa, 2017). This report also explores how older LGBT adults are at an even higher risk of being vulnerable. Overall this report found that “the majority of seniors in our community are doing well, but some groups— such as senior women, LGBTQ+ seniors, Indigenous seniors, newcomer seniors and seniors with disabilities—are more vulnerable to poor outcomes (United Way of Ottawa, 2017, p.26).” An arising issue among older vulnerable populations is compounding disadvantages, also referred to as 'double jeopardy'. For example, if an individual is 85+ and indigenous this is considered as double jeopardy as they have two risk factors that deem them as potentially vulnerable.
The Canadian Nurses Association (2013) has made recommendations to the federal government to optimize health outcomes and by targeting factors associated with vulnerability among the older population and implementing strategies to increase productivity, engagement and active ageing. Apart of decreasing vulnerabilities among any population is educating and creating awareness. Nesbitt & Palomarez (2016) support the importance of educating and properly equipping health care providers to identify, recognize and reduce vulnerabilities among the older population in stating:
Providing improved access to care and reducing the social determinants of disparity is crucial to improving public health. At the same time, for providers, increasing an understanding of the social determinants promotes better models of individualized care to encourage more equitable care. These approaches include increasing provider education on disparities encountered by different populations, practicing active listening skills, and utilizing a patient’s cultural background to promote healthy behaviors (p.1).
Future Directions
Home Care Ontario has made strong recommendations to the government to improve future health and build a stronger home care system by asking for "new medical devices, models of care, and system-wide innovations in remote patient monitoring, virtual wards, remote care delivery, patient reported data and self-management that would allow more care to be delivered at home" (2019, p.2). Ontario is beginning to introduce new models of care incorporating technology to improve home care services, enable patients to better self-manage, and reduce the risk of hospital visits—ultimately reducing the cost of health care on the province while providing more patient-centered care. As an example, SmartCoach is a remote monitoring system integrated into the home using wireless technology to help individuals living with chronic diseases to monitor and self-manage their conditions while living at home. This technology is used to monitor and assess vital signs, provide information on how to self-manage and develop an appropriate care plan, all done without the patient having to leave their own home. SmartCoach enables older adults to remain at home longer, and works toward eliminating accessibility issues due to geographical barriers.
Conclusion
With most hospitals in Ontario operating at 100% capacity the province must make appropriate policy changes and implement strategies to strengthen home care services to better support our aging population (Home Care Ontario, 2019). Ontario's shift toward health teams is a step in the right direction to support inter-professional connectedness to provide more integrated and accessible care. With a rapidly aging population health care professionals must be aware of the impact of social determinants of health throughout the life course and how this may interplay with the onset of chronic disease and susceptibility to vulnerabilities later in life. Health care professionals can better approach and understand complex risk factors on health such as social isolation by utilizing various health models to address multilevel approaches to health. Home care is the future of health for health for our aging population. Thus, we must find ways to streamline, innovate and improve home care services in a way for all older adults to have the same opportunity to receiving services.
References
Canadian Healthcare Association. (2009). Home Care in Canada: From the Margins to the Mainstream. Ottawa.
Canadian Nurse's Association. (2010, November 25). Caring for Vulnerable Canadians: Canada’s Registered Nurses Speak out for Palliative and Compassionate Care. Retrieved from https://www.cna-aiic.ca/-/media/cna/page-content/pdf-en/parliamentary_brief_palliative_care_e.pdf?la=en&hash=BA32CB027A9666EBB01A8D3E08956C0F1B16EFEF
Health and Health Care for an Aging Population [Policy Summary of The Canadian Medical Association]. (2013, December).
Home Care Ontario. (2019, January 14). Deliver More Care at Home to Help End Hallway Medicine-Pre Budget Submission. Retrieved July 25, 2019, from https://www.homecareontario.ca/docs/default-source/ohca-media/4-4a-prebudget-submission-press-release.pdf?sfvrsn=10
Home Care Ontario. More Home care for me and you: Preparing Ontario’s Home Care System for the Challenges of Tomorrow. (2018, February 28). Retrieved May 23, 2019, from https://www.homecareontario.ca/docs/default-source/position-papers/home-care-ontario-more-home-care-for-me-and-you-february-28-2018.pdf?sfvrsn=16
Health Quality Ontario (2013). In-home care for optimizing chronic disease management in the community: an evidence-based analysis. Ontario health technology assessment series, 13(5), 1–65.
Let's make our health system healthier. Health Quality Ontario. (n.d.). Measuring Up 2018. Retrieved July 24, 2019, from https://www.hqontario.ca/System-Performance/Yearly-Reports/Measuring-Up-2018
Malcolm, M., Frost, H., & Cowie, J. (2019). Loneliness and social isolation causal association with health-related lifestyle risk in older adults: a systematic review and meta-analysis protocol. Systematic reviews, 8(1), 48. doi:10.1186/s13643-019-0968-x
Ministry of Health and Long-Term Care. (2018). Health Equity Guideline, 2018. Retrieved July 24, 2019, from http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/protocols_guidelines/Health_Equity_Guideline_2018_en.pdf
Mulligan, C. (2019, May 14). Updated: HSN's overcrowding situation has gone from bad to worse. Retrieved May, 2019, from https://www.sudbury.com/local-news/crisis-hsns-overcrowding-situation-has-gone-from-bad-to-worse-1444600
Nord P. (2009). Alternate level of care: Ontario addresses the long waits. Canadian family physician Medecin de famille canadien, 55(8), 786.
North East Local Health Integration Network. (2014). Retrieved from http://www.nelhin.on.ca/aboutus.aspx
Narushima, M., Liu, J., & Diestelkamp, N. (2018). Lifelong learning in active ageing discourse: its conserving effect on wellbeing, health and vulnerability. Ageing and society, 38(4), 651–675. doi:10.1017/S0144686X16001136
Nesbitt, S., & Palomarez, R. E. (2016). Review: Increasing Awareness and Education on Health Disparities for Health Care Providers. Ethnicity & disease, 26(2), 181–190. doi:10.18865/ed.26.2.181
Office of the Auditor General of Ontario. (2015). Annual Report 2015. Retrieved July 24, 2019, from http://www.auditor.on.ca/en/content/annualreports/arbyyear/ar2015.html
Pinelle, D., & Gutwin, C. (2002). Supporting collaboration in multidisciplinary home care teams. Proceedings. AMIA Symposium, 617–621.
Schröder-Butterfill, E., & Marianti, R. (2006). A framework for understanding old-age vulnerabilities. Ageing and society, 26(1), 9–35. doi:10.1017/S0144686X05004423
Seniors First BC. (n.d.). Vulnerability. Retrieved July 8, 2019, from http://seniorsfirstbc.ca/for-professionals/vulnerability/
Social Development Canada. (2019, March 25). Government of Canada. Retrieved from https://www.canada.ca/en/employment-social-development/programs/seniors-action-report.html
Statistics Canada. (2015, November 30). Receiving care at home. Retrieved from https://www150.statcan.gc.ca/n1/pub/89-652-x/89-652-x2014002-eng.htm
Statistics Canada. (2017, May 03). Age and sex, and type of dwelling data: Key results from the 2016 Census. Retrieved from https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm
United Way Ottawa. (2017, June). A Profile of Vulnerable Seniors in the Ottawa Region. Retrieved July 8, 2019, from https://webcache.googleusercontent.com/search?q=cache:qw5zZzdXC_UJ:https://www.unitedwayottawa.ca/wp-content/uploads/2017/06/A-Profile-of-Vulnerable-Seniors-in-the-Ottawa-Region-EN.pdf &cd=4&hl=en&ct=clnk&gl=ca
United Way Seniors Vulnerability Report. (2011). Retrieved July 8, 2019, from https://cnpea.ca/en/resources/reports/942-united-way-seniors-vulnerability-report
van Dongen, J. J., Lenzen, S. A., van Bokhoven, M. A., Daniëls, R., van der Weijden, T., & Beurskens, A. (2016). Interprofessional collaboration regarding patients' care plans in primary care: a focus group study into influential factors. BMC family practice, 17, 58. doi:10.1186/s12875-016-0456-5
Comments