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We are not alone: an American perspective on long-term care in Nova Scotia.

America's long-term care providers sometimes feel uniquely besieged, but this investigator's journey to the "land of my grandparents" struck some (surprisingly) familiar notes

Long-term care services have been viewed in Nova Scotia in a rather traditional manner. Institution-based care (nursing homes, homes for the aged, special care, etc.) is the cornerstone of the delivery system. There are 70 facilities in the system, serving a provincial population of approximately one million people. Of these facilities, 22 are municipally owned, 21 are private for-profit, 6 are based in hospitals and the remainder are an assortment of private non-profit and charitable organizations. There is a total of 5,883 licensed beds plus 54 respite beds, with the size of the facilities ranging from 8 to 596 beds (Shannex Healthcare Management, Inc., is the largest provider of longterm care with 850 beds). Per diem rates of reimbursement for services rendered range from $69 to $129 (Canadian) per day, the rate depending upon wage differentials, whether the facility is new or old (i.e., principal and interest or principal and depreciation are paid), and facility size. Total budget for 96/97 was $188,000,000, with the provincial Department of Health subsidizing individuals (based on their income level) in the amount of $103,000,000.

Contrary to the view that all medically necessary services are covered in Canada through their social health insurance system, long-term care is not an insured service in Nova Scotia. Perhaps out of tradition, long-term care is not considered to be a "medical service," but rather a "social service." Even though people with dementia accounted for upwards of 65% of the residents in the facilities I visited, and medications were provided and rehabilitation offered, the residents' condition was not deemed to be "medical" for insurance purposes. Instead, the provincial government has a spend-down model - a nursing home requires residents to spend down to their "last dollar" before government subsidies will pay for their care (residents can keep their home and a portion of their assets).

The administrative structure was far "leaner" in nursing homes than in acute hospitals. For instance, at the R.K. MacDonald Nursing Home in Antigonish, 150 employees are managed by seven managers plus one administrator.

The regulations that govern long-term care have been developed primarily as responses to problems. A yearly inspection visit by the province ensures compliance. The Canadian Council on Accreditation also performs on-site surveys, which are gaining more support as a valuable review of a facility's operations. Such visits are more consultative in nature. In my view, though, changes in the provision of services due to technology, educational requirements and cost have resulted in a need for a thorough review by the provincial government of the entire set of rules and regulations that govern long-term care.

Long-term care, although delivered locally, is beginning to see a regional flavor to its operations. Nova Scotia is divided into four regions for health planning purposes. Although not all long-term care providers are participants in the regional councils (most notably missing are home care agencies), this forum does provide an excellent example of an effort at integrating the continuum of care. Nevertheless, delivery of care is quite decentralized, and attempts to remedy this have not gone smoothly. For example, an attempt to integrate the boards of a nursing home (R. K. MacDonald) and a hospital (St. Martha's) in Antigonish has stalled because no provincial law exists to handle such a situation.

Most long-term care providers are located in physical structures that were not originally built for the purposes now served - they were constructed not so much to "deliver care" as to "house people." For example, special care units for Alzheimer's residents are not widely found, in part because of the perceived lack of evidence that segregated units provide better outcomes, and in part because of cost. It is a myth, however, that the Canadian healthcare system puts money into human resources rather than physical resources. Each facility I visited had just been renovated, was being renovated or was about to be. Each facility's leadership was keenly aware of the need to have a clean, safe and healthy environment for residents.

Although these facilities exist to deliver resident care, the type of residents they intend to serve is not clear. Nova Scotia does have a resident classification system, of sorts: Level I Care is personal care (1/2 to 1 hour of care in a 24-hour period) and Level II Care, encompassing nursing supervision and/or nursing care (2 to 2.5 hours of care in a 24-hour period). However, there is no standardized admission assessment process - thus, for example, cognitive impairment is not always documented. Fragmentation of information reigns supreme. Drug utilization data are not available from a centralized data bank (as they are in Alberta). Community health assessments are not well developed, so residents' projected needs are difficult to determine. In short, the classification of residents in longterm facilities is not systematically connected to their needs.

There is, however, good evidence of a steady growth of heavier-care users entering the long-term care system without commensurate resources to provide that care. Within this general limitation, facilities vary their service mix quite a bit, depending upon the facility's mission, size and resources available (physical, human and financial). For example, Sea View Manor Home for Special Care in Glace Bay provides physician services, nursing services, dietary services, housekeeping/laundry, physiotherapy, occupational therapy, religious services and other activities (arts, crafts, games, etc.). It also has an Alzheimer's support group and a volunteer group. Particularly noteworthy was the personal contact made by nursing staff with each prospective resident in his / her home prior to an admission.

In determining appropriate resource allocation, each facility can and does lay claim to a unique position based on its own sense of vision, mission and operational philosophy. Managerial imagination and creativity are encouraged, within the context of the facility's mission and resources. Heritage can be a particularly valuable ally. In Antigonish, with its large Catholic population, the R. K. MacDonald Nursing Home leans heavily on its Catholic roots, although not to the exclusion of non-Catholic residents' needs. This facility was once owned by the Sisters of St. Martha, who now have a management contract to run it. This facility has the most beautiful chapel I have ever seen in my 20 years of traveling to similar facilities in the U.S. and Canada. Its presence and use, for Catholic and non-Catholic services, is seen as key to the success of the facility's mission. Values are an important presence in Nova Scotia's long-term care sector - they are written down and witnessed in all activities and structures.

Reflections

What lessons did I take away from the "heady" experience of watching another country's long-term care system in action? Several thoughts stand out:

1. The continuum of care, or seamless care, concept so often talked about in the American system is appreciated, conceptually, by healthcare policy makers and administrators in Nova Scotia, but is not evident in practice. Given the fact that the Department of Health "competes" with the Community Health Services Department for jurisdiction over longterm care services, it is hard to imagine a true continuum being realized soon. In addition, the regionalization of health services under way has nevertheless allowed for several important players (i.e., large hospitals) to opt out. That fact, coupled with an incomplete "roster of players" involved in long-term care decisionmaking consultation, makes for an impressive barrier to the realization of a true continuum of care.

Furthermore, integration of clinical services, administrative services and physicians is not consistent throughout the system. There are exceptions (the "enriched living" unit at the R.K. MacDonald Nursing Home being an example), but they can best be described as having been accomplished ad hoc. In short, Nova Scotia has a long way to go in setting a standard to follow in the area of the continuum of care.

2. The physical structures in many instances did successfully integrate the physical and social environments. Sea View Manor Home for Special Care is an example. Located directly across the street from a hospital this facility is also bounded by a shoreline, providing a magnificent view for its residents. This seaside-location has not resulted in any accidents due to wandering - a remarkable feat. Another case in point: Ocean View Manor in Eastern Passage. While this 30-year-old building is undergoing a $2.5-million renovation, it too offers a marvelous view of the water, and grounds from which to enjoy the view. Located neither in isolated areas nor in the middle of congested urban areas, and not new, these buildings show a reasonable use of scarce resources in delivering high-quality care to people in need.

3. Nova Scotia has a "policy vacuum." For instance, reports get "commissioned" but somehow don't seem to get turned into legislation (a particular example being the 1995 Community Continuing Care: A New Horizon report). The government knows what it should do, but the political courage to make true longterm care reform a reality is not evident. Though it is true that money is not plentiful at the provincial level more important is the lack of concerted pressure for reform from providers and consumers/clients. Although individual providers and consumers can clearly articulate "the problem" with long-term care, a province-wide consensus on appropriate remedies is not in the offing. It is generally recognized, for instance, that long-term care services need to be "outcomes oriented," but neither provincial policy nor individual institutional policy has been coordinated to make this happen. Although healthcare policy has clearly entered a period of "transition," no one seems confident regarding to what exactly they are "transitioning."

4. Managing a long-term care facility in Nova Scotia is no easy matter. Perhaps the single greatest concern to these managers and those whom they serve is the lack of a single entry point into the system. No standardized assessment tool is utilized. Without the resulting patient database, coordinated service delivery is hampered tremendously. The problem lies partly in technology and partly in cost. Consider, for example, the facility that uses 11-year-old software installed on its one computer to help do some accounting reports, most of which originate as hand-documented entries. This same facility has had a budget freeze for six years (albeit a balanced budget during that time). What the facility has been able to accomplish with such a low level of support has been nothing short of remarkable, but one wonders about the possible impact of this upon quality of care. An upgraded information management system could only help in making better decisions for longterm care clients, particularly as it would lend itself to outcomes research.

5. Image is not everything, but it certainly is something. Long-term care in Nova Scotia labors under the same negative public perceptions that have become so familiar to providers in the U.S. There have also been similarly unfortunate encounters with the media. Such was the case, for example, with the making of the video "Not My Home." Fanlight Production spent weeks at Sea View Manor apparently trying to capture the "essence" of the operations and life at the facility. Instead, unbeknownst to the staff, the finished video became a rallying cry for those who feel that nursing home residents are ill-treated. This product of an apparently preconceived agenda by the filmmaker damaged the reputation of an organization that had opened itself to an outsider's view of its work. Such image mishaps can only be offset by continued vigilance in providing high-quality care, and by continued openness to external review performed, one hopes, fairly and consistently.

6. It is a truism by now that the greatest strength of any organization is its people. In Nova Scotia, I found that the openness of staff and clinicians to interviews, questions and general discussions of their organizations, jobs and fields of endeavor was remarkable. No question was evaded. No part of a facility went "untoured." Candor and politeness were evident at every turn - as, too, was the frustration that comes from job stressors, such as lower-than-expected pay scales, inadequate resources/tools or the infusion of politics into the fray. The overall attitude among staff was one of respect - for who they were, for what they do, and for whom they do it. These are people who provide services in the "present tense" but who realize that (like Mark Twain) they plan on "living in the future."

Such was the case with Keith Menzies, administrator at Ocean View Manor. His interest in longterm care goes beyond his own facility, as witnessed by his involvement with the drafting of the Community Continuing Care document, as well as his participation on a regional council of long-term care providers. But the focus of his life is and must be on immediate concerns. On our tour of his facility, his frank analysis was pertinent and insightful. I often measure administrators' effectiveness by their "people-orientation" - for example, do the residents seem to know him/her, how do they interact, etc. On our tour, Keith took the time to listen to a resident's ongoing concern over the facility's renovation and its impact on her life. In doing so, he reflected a concern with the ultimate reason for his job - to serve other people. And that, of course, is the basis of everything in long-term care, in whatever country. NH

RELATED ARTICLE: Background to a Journey

As a student, teacher, researcher, author and consultant in the field of healthcare administration for more than 20 years, I have moved increasingly toward investigating long-term care services, since more and more they are driving utilization end costs and are being used by more people. As the grandson of Nova Scotians but one who had never visited that province, when I received a sabbatical from my college, the match seemed perfect: on-site research about Nova Scotia's long-term care system. My visits occurred during September 1997. I conducted on-site interviews with providers, government officials and academics involved with long-term care service policy making and administration. Those interviewed included:

* Dean Hirtle, director, Long Term Care, Department of Health, Province of Nova Scotia, Halifax;

* Karen MacIntyre, vice-president and chief operating officer, Shannex Health Care Management, Inc. Halifax;

* Leonarda MacNeil, director of Finance, R.K. MacDonald Nursing Home, Antigonish;

* Keith Menzies, administrator, Ocean View Manor, Eastern Passage; and

* Catherine Power, administrator, Sea View Manor Home for Special Care, Glace Bay.

The openness of each encounter was truly remarkable. My Dalhousie University visit is a case in point. Dr. Grace Johnston, a member of the faculty of the Department of Health Administration, was not only instrumental in setting up many of my interviews, but she also invited me to give a short informal talk at her school as part of my "agenda." Here were faculty and graduate students taking time out of their busy schedules to share in a dialogue with me for two hours about trends and issues in managed care. Such open exchanges lie at the heart of real education, and I am truly indebted to all whom I visited.

Steven A. Mosher, PhD

Steven A. Mosher, PhD, is director of the Health Care Administration Program and professor of Health Care Administration and Political Science at Mary Baldwin College, Staunton, VA. For further information, phone (540)887-7276; fax (540)887-7137; e-mail smosher@cit.mbc.edu.
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Author:Mosher, Steven A.
Publication:Nursing Homes
Date:Sep 1, 1998
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